Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 7, 2023
Have a plan that describes the process for conducting QAPI and QAA activities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 7, 2023
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 7, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 7, 2023
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 Dec 7, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 7, 2023
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 7, 2023
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 Dec 7, 2023
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 7, 2023
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 Dec 7, 2023
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 7, 2023
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 7, 2023
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 Dec 7, 2023
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 7, 2023
Provide safe, appropriate pain management for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 7, 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 Dec 7, 2023
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, isolatedCorrected Dec 7, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 7, 2023
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 Dec 7, 2023
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 7, 2023
Construct fire resistant interior walls.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 7, 2023
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, isolatedCorrected Dec 7, 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 Dec 7, 2023
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Severity B of L: potential for minimal harm, patternCorrected Dec 7, 2023