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 Feb 9, 2024
Have an alternate power supply for its alarm system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 5, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 9, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 9, 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 Feb 9, 2024
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 5, 2024
Establish staff and initial training requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 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 Feb 9, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 9, 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 Feb 9, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 9, 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 Feb 9, 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 Feb 9, 2024
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 9, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 9, 2024
Have approved installation, maintenance and testing program for fire alarm systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Properly provide smoke detection systems in areas open to corridors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 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 Mar 5, 2024
Meet requirements for the use of electrical equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Address patient/client population and determine types of services needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Address subsistence needs for staff and patients.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Establish policies and procedures for medical documentation.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Establish policies and procedures for volunteers.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Provide a means of sharing information on occupancy/needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Provide family notifications of emergency plan.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Establish emergency prep training and testing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Conduct testing and exercise requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024
Install emergency lighting that can last at least 1 1/2 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 5, 2024