Have elevators that firefighters can control in the event of a fire.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 19, 2023
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 Jul 14, 2023
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 Jul 14, 2023
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 19, 2023
Establish procedures for tracking staff and patients during an emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 19, 2023
Establish emergency prep training and testing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 19, 2023
Establish staff and initial training requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 19, 2023
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 19, 2023
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 29, 2023
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 31, 2023
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 25, 2023
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 May 25, 2023
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 Jun 19, 2023
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 19, 2023
Hire a qualified full-time social worker in a facility with more than 120 beds.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 14, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 14, 2023
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 14, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 25, 2023
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 19, 2023
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 14, 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 Jul 14, 2023
Install proper backup exit lighting.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 25, 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 May 30, 2023
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 19, 2023
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 19, 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 Jun 19, 2023
Honor the resident's right to manage his or her financial affairs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 14, 2023
Install properly constructed and protected linen or trash chutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 19, 2023
Implement a program that monitors antibiotic use.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 14, 2023
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 14, 2023
Ensure that residents are free from significant medication errors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 14, 2023
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 Jul 14, 2023
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 Jul 14, 2023
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 14, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 14, 2023
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 19, 2023
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 Jul 14, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 14, 2023
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 25, 2023