Ensure that residents are free from significant medication errors.
Severity G of L: actual harm, isolatedCorrected Oct 27, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 6, 2023
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 6, 2023
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 27, 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 Oct 27, 2023
Implement a program that monitors antibiotic use.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 27, 2023
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 27, 2023
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 27, 2023
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 27, 2023
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 6, 2023
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 6, 2023
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 6, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 2023
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 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 Oct 27, 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 Oct 27, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 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 Oct 27, 2023
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 2023
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 2023
Observe each nurse aide's job performance and give regular training.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 2023
Post nurse staffing information every day.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 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 Oct 27, 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 Oct 27, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 27, 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 Oct 27, 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 Oct 27, 2023
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedWaiver has been granted
