Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 31, 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 Jul 31, 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 Jul 31, 2025
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 31, 2025
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 31, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 31, 2025
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 Jul 31, 2025
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 Jul 31, 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 Jun 11, 2025
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 31, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Jun 11, 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, patternFound during a complaint inspectionCorrected Jun 11, 2025
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 31, 2025
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 Jul 31, 2025
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 31, 2025
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 Jun 11, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 11, 2025
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, isolatedFound during a complaint inspectionCorrected Jun 11, 2025
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 11, 2025
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 11, 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 Jun 11, 2025
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jun 11, 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, isolatedFound during a complaint inspectionCorrected Jun 11, 2025
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 Jun 11, 2025
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, isolatedFound during a complaint inspectionCorrected Jun 11, 2025
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 11, 2025
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jun 11, 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, isolatedCorrected Jun 11, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 11, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 11, 2025
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 11, 2025
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, isolatedFound during a complaint inspectionCorrected Jun 11, 2025
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 11, 2025
Keep all essential equipment working safely.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jun 11, 2025
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jun 11, 2025
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jun 11, 2025
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 31, 2025
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 31, 2025
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 31, 2025
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 31, 2025
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 31, 2025
Post nurse staffing information every day.
Severity B of L: potential for minimal harm, patternCorrected Jun 11, 2025
