Have approved installation, maintenance and testing program for fire alarm systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 24, 2024
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 28, 2024
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 28, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 24, 2024
Establish policies and procedures for medical documentation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 24, 2024
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 24, 2024
Provide a written emergency evacuation plan.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 24, 2024
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 24, 2024
Have properly installed hallway dispensers for alcohol-based hand rub.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 24, 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 Oct 24, 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, isolatedCorrected Oct 28, 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 Oct 28, 2024
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 28, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 28, 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 Oct 28, 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, isolatedCorrected Oct 28, 2024
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 24, 2024
Provide primary/alternate means for communication.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 24, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity C of L: potential for minimal harm, widespreadCorrected Oct 24, 2024
Conduct risk assessment and an All-Hazards approach.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 24, 2024
Address subsistence needs for staff and patients.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 24, 2024
List the names and contact information of those in the facility.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 24, 2024
Install an approved automatic sprinkler system.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 24, 2024
Have simulated fire drills held at unexpected times.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 24, 2024
Have generator or other power source capable of supplying service within 10 seconds.
Severity C of L: potential for minimal harm, widespreadCorrected Oct 24, 2024
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 Oct 28, 2024
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Severity B of L: potential for minimal harm, patternCorrected Oct 28, 2024