Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 10, 2023
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Conduct risk assessment and an All-Hazards approach.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Develop Emergency Preparedness policies and procedures.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Establish procedures for tracking staff and patients during an emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Establish policies and procedures for sheltering.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Establish policies and procedures for volunteers.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Establish roles under a Waiver declared by secretary.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Develop a communication plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Implement emergency and standby power systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Have generator or other power source capable of supplying service within 10 seconds.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 25, 2023
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 11, 2023
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 10, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 10, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 10, 2023
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 25, 2023
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 25, 2023
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 10, 2023
Provide emergency officials' contact information.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
Provide primary/alternate means for communication.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
Establish methods for sharing information.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
Provide a means of sharing information on occupancy/needs.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
Provide family notifications of emergency plan.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
Establish emergency prep training and testing.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
Establish staff and initial training requirements.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
Provide a written emergency evacuation plan.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 25, 2023
