Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 20, 2024
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 16, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Sep 2, 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, patternFound during a complaint inspectionCorrected Aug 29, 2024
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 Sep 16, 2024
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 Aug 29, 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, isolatedFound during a complaint inspectionCorrected Aug 28, 2024
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 Aug 29, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 28, 2024
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2024
Conduct testing and exercise requirements.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 16, 2024
Have properly installed hallway dispensers for alcohol-based hand rub.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 16, 2024
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 16, 2024
Have simulated fire drills held at unexpected times.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 16, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity C of L: potential for minimal harm, widespreadCorrected Sep 16, 2024
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity B of L: potential for minimal harm, patternCorrected Sep 16, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity B of L: potential for minimal harm, patternFound during a complaint inspectionCorrected Aug 28, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity B of L: potential for minimal harm, patternCorrected Sep 13, 2024
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 B of L: potential for minimal harm, patternCorrected Sep 2, 2024