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, widespreadCorrected Jan 12, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity L of L: immediate jeopardy, widespreadCorrected Jan 12, 2024
Have policies on smoking.
Severity L of L: immediate jeopardy, widespreadCorrected Jan 12, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Jan 12, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Jan 12, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 12, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 12, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 12, 2024
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 12, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 12, 2024
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 Jan 12, 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 Jan 12, 2024
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, isolatedFound during a complaint inspectionCorrected Jan 12, 2024
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 2024
Develop Emergency Preparedness policies and procedures.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 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 Jan 12, 2024
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 2024
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 2024
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 2024
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, isolatedFound during a complaint inspectionCorrected Jan 12, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 2024
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jan 12, 2024
Plan the resident's discharge to meet the resident's goals and needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 2024
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 2024
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 Jan 12, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 12, 2024
