Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 11, 2023
Implement emergency and standby power systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 11, 2023
Properly provide smoke detection systems in areas open to corridors.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 11, 2023
Have generator or other power source capable of supplying service within 10 seconds.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 11, 2023
Ensure proper usage of power strips and extension cords.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 11, 2023
Dispose of garbage and refuse properly.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 2, 2023
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 Jun 2, 2023
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 2, 2023
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 2, 2023
Have simulated fire drills held at unexpected times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 11, 2023
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 11, 2023
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 11, 2023
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 2, 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 Jun 2, 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 Jun 2, 2023
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 2, 2023
Provide care or services that was trauma informed and/or culturally competent.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 2, 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 Jun 2, 2023
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2023
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2023
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2023
Have properly located and lighted "Exit" signs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2023
Install emergency lighting that can last at least 1 1/2 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2023
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 11, 2023
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 2, 2023
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, isolatedCorrected Jun 2, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 2, 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 Jun 2, 2023
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 2, 2023
Assure that each resident’s assessment is updated at least once every 3 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 2, 2023
Assess the resident when there is a significant change in condition
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 2, 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 Jun 2, 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 Jun 2, 2023
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 2, 2023