Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 19, 2024
Ensure that testing and maintenance of electrical equipment is performed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 17, 2024
Dispose of garbage and refuse properly.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 15, 2024
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 Oct 15, 2024
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 Dec 17, 2024
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 17, 2024
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 Dec 17, 2024
Install a fire alarm system that can be heard throughout the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 19, 2024
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 19, 2024
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 17, 2024
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2024
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 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 Oct 15, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 15, 2024
Meet other general requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 17, 2024
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 17, 2024
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 17, 2024
Meet other general requirements that are deficient.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 19, 2024
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, isolatedFound during a complaint inspectionCorrected Oct 15, 2024
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 15, 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, isolatedFound during a complaint inspectionCorrected Oct 15, 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 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 Oct 15, 2024
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, isolatedFound during a complaint inspectionCorrected Oct 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, isolatedFound during a complaint inspectionCorrected Oct 15, 2024
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 15, 2024
Provide appropriate foot care.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 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, isolatedFound during a complaint inspectionCorrected Oct 15, 2024
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, isolatedFound during a complaint inspectionCorrected Oct 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, isolatedCorrected Oct 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 D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 15, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 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, isolatedCorrected Oct 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 Oct 15, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 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 D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 15, 2024
Have simulated fire drills held at unexpected times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 15, 2024
Have properly located and lighted "Exit" signs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 19, 2024