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, patternCorrected Jul 29, 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, patternCorrected Jul 29, 2023
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 29, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 29, 2023
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 13, 2023
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 Jul 13, 2023
Have approved installation, maintenance and testing program for fire alarm systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 13, 2023
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 29, 2023
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
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 Jul 29, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 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, isolatedCorrected Jul 29, 2023
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Allow residents to self-administer drugs if determined clinically appropriate.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Make sure that a working call system is available in each resident's bathroom and bathing area.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Keep all essential equipment working safely.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Implement a program that monitors antibiotic use.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
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 Jul 29, 2023
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 13, 2023
Properly provide smoke detection systems in areas open to corridors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 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 Jul 13, 2023
Keep residents' personal and medical records private and confidential.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Have generator or other power source capable of supplying service within 10 seconds.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 13, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Ensure medication error rates are not 5 percent or greater.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 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, isolatedCorrected Jul 29, 2023
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 Jul 29, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
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 Jul 29, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 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, isolatedCorrected Jul 29, 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, isolatedCorrected Jul 29, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 29, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity B of L: potential for minimal harm, patternCorrected Jul 29, 2023
Dispose of garbage and refuse properly.
Severity B of L: potential for minimal harm, patternCorrected Jul 29, 2023
