Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity G of L: actual harm, isolatedCorrected Apr 20, 2026
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 20, 2026
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 22, 2026
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 20, 2026
Implement a program that monitors antibiotic use.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 20, 2026
Observe each nurse aide's job performance and give regular training.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 20, 2026
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, patternCorrected Apr 20, 2026
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 20, 2026
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2026
Have exits that are accessible at all times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 22, 2026
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 Apr 20, 2026
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 Apr 20, 2026
Ensure medication error rates are not 5 percent or greater.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 20, 2026
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 20, 2026
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 20, 2026
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 20, 2026
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 20, 2026
Develop and maintain an Emergency Preparedness Program (EP).
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
Provide properly protected cooking facilities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
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 Apr 20, 2026
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 20, 2026
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, isolatedCorrected Apr 20, 2026
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, isolatedCorrected Apr 20, 2026
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 20, 2026
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 20, 2026
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 20, 2026
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, isolatedCorrected Apr 20, 2026
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 Apr 20, 2026
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 Apr 20, 2026
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 20, 2026
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 20, 2026
Provide routine and 24-hour emergency dental care for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 20, 2026
Have generator or other power source capable of supplying service within 10 seconds.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
Have simulated fire drills held at unexpected times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
Install properly constructed and protected linen or trash chutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
Meet other general requirements that are deficient.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
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 May 22, 2026
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 22, 2026
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity B of L: potential for minimal harm, patternCorrected Apr 20, 2026
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity B of L: potential for minimal harm, patternCorrected Apr 20, 2026
Ensure each resident receives an accurate assessment.
Severity B of L: potential for minimal harm, patternCorrected Apr 20, 2026