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 Sep 23, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 23, 2024
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 23, 2024
Observe each nurse aide's job performance and give regular training.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 23, 2024
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 23, 2024
Have approved installation, maintenance and testing program for fire alarm systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 14, 2024
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 14, 2024
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 17, 2024
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 Oct 14, 2024
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 14, 2024
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 Oct 14, 2024
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 Oct 14, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 23, 2024
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 23, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 23, 2024
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 14, 2024
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 14, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 14, 2024
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 23, 2024
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 23, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 23, 2024
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 Sep 23, 2024
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 Sep 23, 2024
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 23, 2024
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 23, 2024
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 Sep 23, 2024
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 Sep 23, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 23, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 23, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 23, 2024
Post nurse staffing information every day.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 23, 2024
