Keep all essential equipment working safely.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Mar 24, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Mar 24, 2024
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Mar 24, 2024
Provide and implement an infection prevention and control program.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Mar 24, 2024
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Mar 24, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Mar 24, 2024
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity G of L: actual harm, isolatedCorrected Mar 24, 2024
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 Mar 24, 2024
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 24, 2024
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 Mar 24, 2024
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, patternFound during a complaint inspectionCorrected Mar 24, 2024
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 Mar 24, 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, isolatedCorrected Mar 24, 2024
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 Mar 24, 2024
Assist a resident in gaining access to vision and hearing services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 24, 2024
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 24, 2024
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 Mar 24, 2024
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, isolatedFound during a complaint inspectionCorrected Mar 24, 2024
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 10, 2024