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 9, 2019
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 9, 2019
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 9, 2019
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 9, 2019
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 Oct 9, 2019
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 9, 2019
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 9, 2019
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 9, 2019
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 9, 2019
Meet requirements for the installation and maintenance of electrical systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 9, 2019
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 9, 2019
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 25, 2019
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 9, 2019
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 9, 2019
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 Oct 9, 2019
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 9, 2019
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 Oct 9, 2019
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 9, 2019
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 9, 2019
Establish emergency prep training and testing.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Develop and maintain an Emergency Preparedness Program (EP).
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Address patient/client population and determine types of services needed.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Develop Emergency Preparedness policies and procedures.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Establish procedures for tracking staff and patients during an emergency.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Establish policies and procedures including evacuation.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Establish policies and procedures for volunteers.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Establish roles under a Waiver declared by secretary.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Develop a communication plan.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
List the names and contact information of those in the facility.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Provide emergency officials' contact information.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Provide a means of sharing information on occupancy/needs.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 9, 2019
Install a fire alarm system that can be heard throughout the facility.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Meet requirements for sections of health care facilities separated by fire resistive construction.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
Establish staff and initial training requirements.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has plan of correction
