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 Oct 13, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 13, 2023
Have exits that are accessible at all times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 13, 2023
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 13, 2023
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 13, 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 Oct 13, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 13, 2023
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 F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 13, 2023
Provide activities to meet all resident's needs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 13, 2023
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 F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 13, 2023
Ensure each resident receives an accurate assessment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 13, 2023
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Oct 13, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Oct 13, 2023
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, patternFound during a complaint inspectionCorrected Oct 13, 2023
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, patternFound during a complaint inspectionCorrected Oct 13, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Oct 13, 2023
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, isolatedFound during a complaint inspectionCorrected Oct 13, 2023
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, isolatedFound during a complaint inspectionCorrected Oct 13, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 13, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 13, 2023
Post nurse staffing information every day.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 13, 2023
Provide timely, quality laboratory services/tests to meet the needs of residents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 13, 2023
Conduct risk assessment and an All-Hazards approach.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 13, 2023
Include a process for Emergency Preparedness collaboration.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 13, 2023
Establish staff and initial training requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 13, 2023
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 13, 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 Oct 13, 2023
Provide properly protected cooking facilities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 13, 2023
Have approved installation, maintenance and testing program for fire alarm systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 13, 2023
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 13, 2023
Ensure that testing and maintenance of electrical equipment is performed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 13, 2023
