Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 31, 2022
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 Jun 24, 2022
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 31, 2022
Install corridor and hallway doors that block smoke.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 24, 2022
Have properly installed electrical wiring and gas equipment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 24, 2022
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 31, 2022
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 May 17, 2022
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 30, 2022
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 17, 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 May 17, 2022
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 May 17, 2022
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 17, 2022
Perform COVID19 testing on residents and staff.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 17, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 17, 2022
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 17, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 17, 2022
Ensure that residents are free from significant medication errors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 17, 2022
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 17, 2022
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 17, 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 May 17, 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 May 17, 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 May 17, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 17, 2022
