Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity G of L: actual harm, isolatedCorrected Jun 16, 2022
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 16, 2022
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 13, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 16, 2022
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, patternCorrected Jun 16, 2022
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 16, 2022
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 16, 2022
Ensure medication error rates are not 5 percent or greater.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 16, 2022
Ensure that residents are free from significant medication errors.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 16, 2022
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 16, 2022
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, patternCorrected Jun 16, 2022
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 16, 2022
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 13, 2022
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 May 13, 2022
Meet requirements for the use of electrical equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 13, 2022
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 16, 2022
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 16, 2022
Ensure that residents are fully informed and understand their health status, care and treatments.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 16, 2022
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2022
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2022
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 May 13, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 16, 2022
Establish policies and procedures for medical documentation.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2022
List the names and contact information of those in the facility.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2022
Establish staff and initial training requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2022
Conduct testing and exercise requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2022
Implement emergency and standby power systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2022
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2022
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 13, 2022
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 16, 2022
Ensure staff are vaccinated for COVID-19
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 16, 2022
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 16, 2022