Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 3, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 3, 2023
Install an approved automatic sprinkler system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 3, 2023
Have exits that are accessible at all times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 3, 2023
Ensure staff are vaccinated for COVID-19
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 6, 2023
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, patternCorrected Apr 6, 2023
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 6, 2023
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, patternCorrected Apr 6, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 6, 2023
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 6, 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 Apr 6, 2023
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 6, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 6, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 6, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 6, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 6, 2023
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 6, 2023
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 6, 2023
Have simulated fire drills held at unexpected times.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Meet requirements for the installation and maintenance of electrical systems.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Have generator or other power source capable of supplying service within 10 seconds.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Ensure that testing and maintenance of electrical equipment is performed.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Conduct risk assessment and an All-Hazards approach.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Provide properly protected cooking facilities.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Install a fire alarm system that can be heard throughout the facility.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Install corridor and hallway doors that block smoke.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 3, 2023