Ensure that residents are free from significant medication errors.
Severity J of L: immediate jeopardy, isolatedCorrected May 13, 2025
Provide emergency officials' contact information.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 20, 2025
Include a process for Emergency Preparedness collaboration.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 20, 2025
Install properly constructed and protected linen or trash chutes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 20, 2025
Use approved construction type or materials.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 20, 2025
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 20, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 17, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 13, 2025
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 17, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 29, 2025
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2025
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 13, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 29, 2025
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 Jun 17, 2025
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 May 13, 2025
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 29, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity C of L: potential for minimal harm, widespreadCorrected May 29, 2025
Provide a written emergency evacuation plan.
Severity C of L: potential for minimal harm, widespreadCorrected Jun 20, 2025
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity C of L: potential for minimal harm, widespreadCorrected Jun 20, 2025
Post nurse staffing information every day.
Severity B of L: potential for minimal harm, patternCorrected May 13, 2025
Assure that each resident’s assessment is updated at least once every 3 months.
Severity B of L: potential for minimal harm, patternCorrected May 29, 2025