Honor the resident's right to manage his or her financial affairs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Give residents a notice of rights, rules, services and charges.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
The resident has the right to receive notices in a format and a language he or she understands.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Provide information about how to apply for and use Medicare and Medicaid benefits.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Protect each resident from the wrongful use of the resident's belongings or money.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Respond appropriately to all alleged violations.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Prepare residents for a safe transfer or discharge from the nursing home.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 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 Nov 20, 2024
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 29, 2024
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 4, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 26, 2024
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 1, 2024
Dispose of garbage and refuse properly.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 20, 2024
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 20, 2024
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 9, 2024
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Reasonably accommodate the needs and preferences of each resident.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Provide immediate access to any resident.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Have restrictions on the use of flammable curtains.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
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 Oct 25, 2024
Establish policies and procedures for sheltering.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 2024
Establish policies and procedures for medical documentation.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 2024
Establish policies and procedures for volunteers.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 2024
Establish staff and initial training requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 1, 2024
Have properly spaced exits within rooms.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Install proper backup exit lighting.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 14, 2024
Establish methods for sharing information.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 1, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 3, 2024
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 25, 2024
Have a Compliance and Ethics Program.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Keep all essential equipment working safely.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 25, 2024
Provide appropriate foot care.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Assist a resident in gaining access to vision and hearing services.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 14, 2024
Provide appropriate care/assistance for a resident with a prosthesis.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Provide care or services that was trauma informed and/or culturally competent.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 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 C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Post nurse staffing information every day.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 29, 2024
Provide routine and 24-hour emergency dental care for each resident.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 4, 2024
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 1, 2024
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 31, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 30, 2024
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity C of L: potential for minimal harm, widespreadCorrected Oct 1, 2024