Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 16, 2022
Implement a program that monitors antibiotic use.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 16, 2022
Perform COVID19 testing on residents and staff.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 16, 2022
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 16, 2022
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 16, 2022
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 16, 2022
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 16, 2022
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 16, 2022
Keep complete, dated laboratory records in the resident's record.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 16, 2022
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 Apr 16, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
Honor the resident's right to manage his or her financial affairs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
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 Apr 16, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
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 Apr 16, 2022
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 Apr 16, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
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 Apr 16, 2022
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 Apr 16, 2022
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 Apr 16, 2022
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
Dispose of garbage and refuse properly.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 16, 2022
Install proper backup exit lighting.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 2022
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 2022
Have simulated fire drills held at unexpected times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 2022
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 2022
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 Aug 4, 2022
Establish roles under a Waiver declared by secretary.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Provide emergency officials' contact information.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Provide primary/alternate means for communication.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Establish methods for sharing information.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Establish policies and procedures including evacuation.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Establish policies and procedures for sheltering.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Establish policies and procedures for medical documentation.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Establish policies and procedures for volunteers.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Create arrangements with other facilities to receive patients.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
List the names and contact information of those in the facility.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
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 Apr 16, 2022
Conduct testing and exercise requirements.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Establish staff and initial training requirements.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Establish emergency prep training and testing.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Provide family notifications of emergency plan.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Provide a means of sharing information on occupancy/needs.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Conduct risk assessment and an All-Hazards approach.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Address patient/client population and determine types of services needed.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Develop Emergency Preparedness policies and procedures.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Address subsistence needs for staff and patients.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
Establish procedures for tracking staff and patients during an emergency.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 16, 2022
