Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 9, 2024
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 9, 2024
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 9, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected May 9, 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, patternCorrected May 9, 2024
Address subsistence needs for staff and patients.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2024
Establish procedures for tracking staff and patients during an emergency.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2024
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2024
Install a fire alarm system that can be heard throughout the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 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 May 20, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2024
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2024
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2024
Provide a written emergency evacuation plan.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 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 May 20, 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 May 20, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 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 May 9, 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 May 9, 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, isolatedCorrected May 9, 2024
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 2024
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 9, 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 May 9, 2024
