Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Severity L of L: immediate jeopardy, widespreadCorrected Nov 12, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity L of L: immediate jeopardy, widespreadCorrected Nov 12, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity J of L: immediate jeopardy, isolatedCorrected Nov 12, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity J of L: immediate jeopardy, isolatedCorrected Nov 12, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Nov 12, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 12, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 12, 2025
Provide training in compliance and ethics.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 12, 2025
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 12, 2025
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 15, 2025
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 15, 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 Dec 15, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 15, 2025
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 15, 2025
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 15, 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 Dec 30, 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 Dec 15, 2025
Address patient/client population and determine types of services needed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 5, 2026
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 15, 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 Nov 12, 2025
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 Nov 12, 2025
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 Nov 12, 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 Nov 12, 2025
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 12, 2025
Implement a program that monitors antibiotic use.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Nov 12, 2025
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 12, 2025
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 12, 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 Nov 12, 2025
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity E of L: no actual harm, potential for more than minimal harm, patternDeficient, Provider has plan of correction
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 15, 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 Dec 15, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Nov 12, 2025
Provide activities to meet all resident's needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 12, 2025
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 Nov 12, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 12, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Nov 12, 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 Nov 12, 2025
Have exits that are accessible at all times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 15, 2025
Have properly installed electrical wiring and gas equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 15, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 12, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 12, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 12, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 12, 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 Nov 12, 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 Nov 12, 2025
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 Nov 12, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 12, 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 Nov 12, 2025
Provide care or services that was trauma informed and/or culturally competent.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 12, 2025
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 12, 2025
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 Nov 12, 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, isolatedCorrected Nov 12, 2025
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Nov 12, 2025
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 15, 2025
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 15, 2025
Install properly constructed and protected linen or trash chutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 15, 2025
Provide properly protected cooking facilities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 15, 2025
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 15, 2025
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity C of L: potential for minimal harm, widespreadCorrected Nov 12, 2025
