Respond appropriately to all alleged violations.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected Feb 24, 2025
Establish policies and procedures for sheltering.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
Address subsistence needs for staff and patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Apr 5, 2025
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
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 Apr 5, 2025
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Jun 15, 2025
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
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 Apr 5, 2025
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
Meet requirements for the installation and maintenance of electrical systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
List the names and contact information of those in the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
Create arrangements with other facilities to receive patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 5, 2025
Honor the resident's right to manage his or her financial affairs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Meet requirements for the use of electrical equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
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 Apr 5, 2025
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
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 Apr 5, 2025
Meet other general requirements that are deficient.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Have exits that are accessible at all times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
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 Apr 5, 2025
Use approved construction type or materials.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Meet other general requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Jun 15, 2025
Ensure the activities program is directed by a qualified professional.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 5, 2025
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Keep all essential equipment working safely.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Implement a program that monitors antibiotic use.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
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 E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 5, 2025
Post nurse staffing information every day.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Apr 5, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 5, 2025
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 Apr 5, 2025
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 Apr 5, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 5, 2025
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 Feb 24, 2025
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 Apr 5, 2025
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 5, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 5, 2025
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 Apr 5, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 15, 2025
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 5, 2025
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 15, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 5, 2025
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 15, 2025
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 Jun 15, 2025
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 Apr 5, 2025
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 Apr 5, 2025
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 Apr 5, 2025
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Apr 5, 2025
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 5, 2025