Install an approved automatic sprinkler system.
Severity L of L: immediate jeopardy, widespreadCorrected Dec 2, 2024
Make sure that a working call system is available in each resident's bathroom and bathing area.
Severity K of L: immediate jeopardy, patternFound during a complaint inspectionCorrected Nov 15, 2024
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 Dec 2, 2024
Use approved construction type or materials.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 15, 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 Nov 15, 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 E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 15, 2024
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, patternFound during a complaint inspectionCorrected Nov 15, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 15, 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 E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 15, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Dec 16, 2024
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 15, 2024
Have a plan that describes the process for conducting QAPI and QAA activities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 15, 2024
Ensure that testing and maintenance of electrical equipment is performed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Have generator or other power source capable of supplying service within 10 seconds.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 22, 2024
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
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 Dec 2, 2024
Have simulated fire drills held at unexpected times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2024
Have elevators that firefighters can control in the event of a fire.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 27, 2024
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 Dec 2, 2024
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 5, 2024
Install emergency lighting that can last at least 1 1/2 hours.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Install proper backup exit lighting.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 2, 2024
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 15, 2024
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 15, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 15, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 15, 2024
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 Nov 15, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 15, 2024
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 Nov 15, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 15, 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 Nov 15, 2024
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 15, 2024
Observe each nurse aide's job performance and give regular training.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Nov 15, 2024
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 Nov 15, 2024
Ensure that residents are free from significant medication errors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Dec 16, 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 Nov 15, 2024
Provide or obtain dental services for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 15, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 15, 2024
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 15, 2024
Have an enclosure around a vertical opening shaft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 2, 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 Dec 2, 2024
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 2, 2024
Provide family notifications of emergency plan.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 27, 2024
Address subsistence needs for staff and patients.
Severity C of L: potential for minimal harm, widespreadCorrected Dec 2, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity C of L: potential for minimal harm, widespreadCorrected Dec 2, 2024
Conduct testing and exercise requirements.
Severity C of L: potential for minimal harm, widespreadCorrected Dec 2, 2024
Establish emergency prep training and testing.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 27, 2024