Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Severity K of L: immediate jeopardy, patternCorrected Mar 18, 2023
Provide enough food/fluids to maintain a resident's health.
Severity G of L: actual harm, isolatedCorrected Nov 27, 2022
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 18, 2023
Ensure the activities program is directed by a qualified professional.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 18, 2023
Have an alternate power supply for its alarm system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 18, 2023
Have approved installation, maintenance and testing program for fire alarm systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 24, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 18, 2023
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 24, 2023
Meet other general requirements that are deficient.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 18, 2023
Have generator or other power source capable of supplying service within 10 seconds.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 18, 2023
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 Jan 18, 2023
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2022
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 24, 2023
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 18, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
Provide activities to meet all resident's needs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
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 Nov 27, 2022
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
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 Mar 3, 2023
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2022
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 Nov 27, 2022
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, widespreadCorrected Mar 3, 2023
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 Mar 3, 2023
Hire a qualified full-time social worker in a facility with more than 120 beds.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 3, 2023
Implement a program that monitors antibiotic use.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2022
Perform COVID19 testing on residents and staff.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 27, 2022
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, widespreadCorrected Nov 27, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2022
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, patternCorrected Mar 3, 2023
Prepare residents for a safe transfer or discharge from the nursing home.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 2023
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 2023
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 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 Mar 3, 2023
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 Mar 18, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 2023
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 2023
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 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 Mar 3, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 18, 2023
Ensure that residents are free from significant medication errors.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 2023
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2022
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2022
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 18, 2023
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 2023
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2022
Keep all essential equipment working safely.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 2023
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2022
Make sure that a working call system is available in each resident's bathroom and bathing area.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 3, 2023
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2022
Meet other general requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 18, 2023
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 18, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 18, 2023
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 18, 2023
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 18, 2023
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 18, 2023
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 18, 2023
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 24, 2023
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 18, 2023
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 3, 2023
Assure that each resident’s assessment is updated at least once every 3 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 27, 2022
Protect each resident from the wrongful use of the resident's belongings or money.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 27, 2022
Have restrictions on the use of portable space heaters.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 18, 2023
Install proper backup exit lighting.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 18, 2023
Meet other general requirements that are deficient.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 18, 2023
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 18, 2023
Install an approved automatic sprinkler system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 18, 2023
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 18, 2023
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 Jan 18, 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 Jan 18, 2023
Provide or get specialized rehabilitative services as required for a resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 27, 2022
Provide routine and 24-hour emergency dental care for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 27, 2022
Keep complete, dated laboratory records in the resident's record.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 27, 2022
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 27, 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 Nov 27, 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 Mar 3, 2023
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 Nov 27, 2022
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 3, 2023
Post nurse staffing information every day.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 27, 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 C of L: potential for minimal harm, widespreadCorrected Nov 27, 2022
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 3, 2023
