Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity K of L: immediate jeopardy, patternFound during a complaint inspectionCorrected May 30, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity G of L: actual harm, isolatedCorrected May 30, 2025
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 May 20, 2025
Develop Emergency Preparedness policies and procedures.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 29, 2025
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 30, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 30, 2025
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 30, 2025
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 30, 2025
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 30, 2025
Address patient/client population and determine types of services needed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 29, 2025
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected May 30, 2025
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 30, 2025
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 30, 2025
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 25, 2025
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 22, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 30, 2025
Have restrictions on the use of portable space heaters.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 30, 2025
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 24, 2025
Properly provide smoke detection systems in areas open to corridors.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2025
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 24, 2025
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 May 30, 2025
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 30, 2025
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 30, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 30, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 30, 2025
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected May 30, 2025
Have an enclosure around a vertical opening shaft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 29, 2025
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 May 30, 2025
Assist a resident in gaining access to vision and hearing services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 2025
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 2025
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 May 30, 2025
Ensure medication error rates are not 5 percent or greater.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected May 30, 2025
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 2025
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 2025
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 23, 2025
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 30, 2025
Install properly constructed and protected linen or trash chutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 2025
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 30, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 24, 2025