Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2023
Install an approved automatic sprinkler system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2023
Have exits that are accessible at all times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 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 Sep 30, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 15, 2023
Install emergency lighting that can last at least 1 1/2 hours.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 30, 2023
Have approved installation, maintenance and testing program for fire alarm systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 30, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 15, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 15, 2023
Ensure medication error rates are not 5 percent or greater.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 15, 2023
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 15, 2023
Provide care or services that was trauma informed and/or culturally competent.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 2023
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 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 Sep 15, 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 Sep 15, 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 Sep 15, 2023
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 15, 2023
Implement emergency and standby power systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2023
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2023
Have an externally vented heating system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2023
Install properly constructed and protected linen or trash chutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2023
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 15, 2023
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 2023
Assess the resident when there is a significant change in condition
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 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 Sep 15, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 2023
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 Sep 15, 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 Sep 15, 2023
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 15, 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 Sep 15, 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 Sep 15, 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 Sep 15, 2023