Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 30, 2024
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 30, 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 Apr 30, 2024
Have properly installed electrical wiring and gas equipment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 30, 2024
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Dec 15, 2023
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Dec 15, 2023
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 Apr 30, 2024
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Dec 15, 2023
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 Dec 15, 2023
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Dec 15, 2023
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, patternFound during a complaint inspectionCorrected Dec 15, 2023
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, patternFound during a complaint inspectionCorrected Dec 15, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Dec 15, 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 Dec 15, 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 Apr 30, 2024
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 Apr 30, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 30, 2024
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 30, 2024
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 30, 2024
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 30, 2024
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 30, 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, isolatedFound during a complaint inspectionCorrected Dec 15, 2023
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Dec 15, 2023
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, isolatedFound during a complaint inspectionCorrected Dec 15, 2023
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 B of L: potential for minimal harm, patternFound during a complaint inspectionCorrected Dec 15, 2023