Establish policies and procedures including evacuation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 31, 2026
Establish staff and initial training requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 31, 2026
Provide family notifications of emergency plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Provide a means of sharing information on occupancy/needs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Establish methods for sharing information.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Provide emergency officials' contact information.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
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 Feb 18, 2026
Create arrangements with other facilities to receive patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Establish policies and procedures for sheltering.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Meet other general requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 31, 2026
Establish procedures for tracking staff and patients during an emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Include a process for Emergency Preparedness collaboration.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Conduct risk assessment and an All-Hazards approach.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 31, 2026
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 31, 2026
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 Feb 18, 2026
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 31, 2026
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
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 Mar 31, 2026
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
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 Mar 31, 2026
Install proper backup exit lighting.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
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 Feb 25, 2026
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 25, 2026
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 31, 2026
Ensure that testing and maintenance of electrical equipment is performed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 31, 2026
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 Mar 31, 2026
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 Mar 31, 2026
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
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 Mar 31, 2026
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 2026
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 18, 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 Feb 25, 2026
Have an enclosure around a vertical opening shaft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 18, 2026
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, patternCorrected Feb 25, 2026
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 25, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 18, 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 Feb 25, 2026
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 25, 2026
Implement a program that monitors antibiotic use.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 25, 2026
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 18, 2026
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 18, 2026
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 Feb 25, 2026
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 2026
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 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 Feb 25, 2026
Assess the resident when there is a significant change in condition
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 2026
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 2026
PASARR screening for Mental disorders or Intellectual Disabilities
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 2026
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 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 Feb 25, 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 Feb 25, 2026
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 Feb 25, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 25, 2026
Provide or get specialized rehabilitative services as required for a resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Feb 25, 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 Feb 25, 2026
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 18, 2026
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 18, 2026
Have properly installed electrical wiring and gas equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 18, 2026
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 18, 2026
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 Feb 25, 2026