Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 8, 2022
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 8, 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 Oct 8, 2022
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 Oct 8, 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 Oct 8, 2022
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2022
Ensure staff are vaccinated for COVID-19
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2022
Reasonably accommodate the needs and preferences of each resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2022
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2022
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2022
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 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 Oct 8, 2022
Provide safe and appropriate respiratory care for a resident when needed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2022
Provide enough food/fluids to maintain a resident's health.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 8, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 8, 2022
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, isolatedCorrected Oct 8, 2022
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 Oct 8, 2022
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 8, 2022
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 8, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 8, 2022
Have simulated fire drills held at unexpected times.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 8, 2022
