Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity J of L: immediate jeopardy, isolatedCorrected Feb 15, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Mar 7, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 15, 2024
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 15, 2024
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 23, 2024
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 15, 2024
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 Feb 15, 2024
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 Feb 15, 2024
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 15, 2024
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 Feb 15, 2024
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Mar 7, 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 E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Mar 7, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 15, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Mar 7, 2024
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 Feb 15, 2024
Ensure medication error rates are not 5 percent or greater.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Feb 15, 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 Feb 15, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Feb 15, 2024
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 Mar 6, 2024
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 Feb 15, 2024
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 15, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 15, 2024
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 5, 2024
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 5, 2024
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 5, 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 Feb 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, isolatedFound during a complaint inspectionCorrected Feb 15, 2024
Implement a program that monitors antibiotic use.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 15, 2024
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 15, 2024
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 15, 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 Feb 15, 2024
Ensure that residents are free from significant medication errors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 4, 2024
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 Jan 5, 2024
Post nurse staffing information every day.
Severity C of L: potential for minimal harm, widespreadCorrected Feb 15, 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 C of L: potential for minimal harm, widespreadCorrected Feb 15, 2024
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 Feb 15, 2024
The resident has the right to receive notices in a format and a language he or she understands.
Severity B of L: potential for minimal harm, patternCorrected Feb 15, 2024