Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected Apr 30, 2024
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 5, 2024
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 5, 2024
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 5, 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 5, 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 Oct 5, 2024
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 5, 2024
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 5, 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, widespreadFound during a complaint inspectionCorrected Oct 5, 2024
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 11, 2024
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 11, 2024
Properly provide smoke detection systems in areas open to corridors.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 11, 2024
Install corridor and hallway doors that block smoke.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 11, 2024
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 11, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 5, 2024
Respond appropriately to all alleged violations.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 5, 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 Oct 5, 2024
Post nurse staffing information every day.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 5, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 5, 2024
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 5, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 11, 2024
Ensure medication error rates are not 5 percent or greater.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 5, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Oct 5, 2024
Have generator or other power source capable of supplying service within 10 seconds.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 11, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 5, 2024
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, isolatedFound during a complaint inspectionCorrected Oct 5, 2024
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, isolatedFound during a complaint inspectionCorrected Oct 5, 2024
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 5, 2024
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, isolatedFound during a complaint inspectionCorrected Oct 5, 2024
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 Oct 5, 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 Oct 5, 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 Oct 5, 2024
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 5, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 11, 2024
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 Oct 5, 2024
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 Oct 5, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 5, 2024
Keep all essential equipment working safely.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 5, 2024
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 5, 2024
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 5, 2024
Install an approved automatic sprinkler system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 8, 2025
