Install proper backup exit lighting.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 16, 2023
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 6, 2023
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 8, 2023
Meet requirements for the installation and maintenance of electrical systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 6, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 1, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 13, 2023
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 19, 2023
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 8, 2023
Assure the security of all personal funds of residents deposited with the facility.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 1, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 1, 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 Aug 1, 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 Aug 1, 2023
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 1, 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 Aug 1, 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 Aug 1, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 1, 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 Aug 1, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 1, 2023
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 Aug 1, 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 Aug 1, 2023
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 1, 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 Aug 1, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 15, 2023
Have exits that are accessible at all times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 6, 2023
Install an approved automatic sprinkler system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 20, 2023
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity C of L: potential for minimal harm, widespreadCorrected Aug 20, 2023
Have generator or other power source capable of supplying service within 10 seconds.
Severity C of L: potential for minimal harm, widespreadCorrected Jul 26, 2023
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity B of L: potential for minimal harm, patternCorrected Aug 1, 2023