Provide a written emergency evacuation plan.
Severity K of L: immediate jeopardy, patternCorrected Mar 17, 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 Mar 17, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Jan 13, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 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 Jan 13, 2025
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 17, 2025
Conduct risk assessment and an All-Hazards approach.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Develop Emergency Preparedness policies and procedures.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Create arrangements with other facilities to receive patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Establish roles under a Waiver declared by secretary.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Implement emergency and standby power systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 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, widespreadWaiver has been granted
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Install corridor and hallway doors that block smoke.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 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 Jan 13, 2025
Ensure that testing and maintenance of electrical equipment is performed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Assure the security of all personal funds of residents deposited with the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Give residents a notice of rights, rules, services and charges.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 13, 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 Jan 13, 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 Jan 13, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Provide training in compliance and ethics.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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 Jan 13, 2025
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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 Jan 13, 2025
Meet requirements for the use of electrical equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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 Jan 13, 2025
Establish policies and procedures including evacuation.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Meet other general requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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, patternCorrected Jan 13, 2025
Have an enclosure around a vertical opening shaft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Reasonably accommodate the needs and preferences of each resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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, patternFound during a complaint inspectionCorrected Jan 13, 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, patternFound during a complaint inspectionCorrected Jan 13, 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 Jan 13, 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, patternCorrected Jan 13, 2025
Protect each resident from the wrongful use of the resident's belongings or money.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Jan 13, 2025
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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, patternCorrected Mar 17, 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 Jan 13, 2025
Provide appropriate foot care.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 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, patternCorrected Jan 13, 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 Jan 13, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 13, 2025
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Mar 17, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 13, 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 Jan 13, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 13, 2025
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 Jan 13, 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 Jan 13, 2025
Assist a resident in gaining access to vision and hearing services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 13, 2025
Provide or obtain dental services for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 13, 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 C of L: potential for minimal harm, widespreadCorrected Jan 13, 2025
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity C of L: potential for minimal harm, widespreadCorrected Jan 13, 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 Jan 13, 2025
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Severity C of L: potential for minimal harm, widespreadCorrected Jan 13, 2025
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Severity B of L: potential for minimal harm, patternCorrected Jan 13, 2025
Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
Severity B of L: potential for minimal harm, patternCorrected Jan 13, 2025
