Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Severity K of L: immediate jeopardy, patternCorrected Oct 23, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity K of L: immediate jeopardy, patternCorrected Oct 23, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity K of L: immediate jeopardy, patternCorrected Oct 23, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity K of L: immediate jeopardy, patternCorrected Oct 23, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity H of L: actual harm, patternCorrected Oct 24, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Severity G of L: actual harm, isolatedCorrected Oct 23, 2024
Provide enough food/fluids to maintain a resident's health.
Severity G of L: actual harm, isolatedCorrected Oct 23, 2024
Implement a program that monitors antibiotic use.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 15, 2024
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 15, 2024
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 23, 2024
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 23, 2024
Establish staff and initial training requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 30, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 22, 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 Oct 22, 2024
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 22, 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 22, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 23, 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 23, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 29, 2024
Conduct risk assessment and an All-Hazards approach.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 31, 2024
Address subsistence needs for staff and patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 29, 2024
Establish procedures for tracking staff and patients during an emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 31, 2024
Provide emergency officials' contact information.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 30, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 15, 2024
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 22, 2024
Keep residents' personal and medical records private and confidential.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 22, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 15, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 23, 2024
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 Oct 23, 2024
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 Oct 22, 2024
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 23, 2024
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 23, 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 15, 2024
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 22, 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 23, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 22, 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 22, 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 22, 2024
Assess the resident when there is a significant change in condition
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 15, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 22, 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, isolatedCorrected Nov 15, 2024
