Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 10, 2025
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 26, 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 Sep 12, 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 Sep 10, 2025
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 Sep 11, 2025
Use approved construction type or materials.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 10, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 23, 2025
Provide properly protected cooking facilities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 8, 2025
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
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 Sep 11, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 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 Sep 11, 2025
Ensure medication error rates are not 5 percent or greater.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
Dispose of garbage and refuse properly.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 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 Sep 11, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 11, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 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 Sep 11, 2025
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 24, 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, isolatedCorrected Sep 11, 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 Sep 11, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 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 Sep 11, 2025
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 Sep 7, 2025
Have power receptacles that are properly grounded.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 10, 2025
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity C of L: potential for minimal harm, widespreadCorrected Aug 21, 2025
Implement emergency and standby power systems.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 26, 2025
Have simulated fire drills held at unexpected times.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 3, 2025
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Severity B of L: potential for minimal harm, patternDeficient, Provider has no plan of correction
Ensure each resident receives an accurate assessment.
Severity B of L: potential for minimal harm, patternCorrected Sep 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 B of L: potential for minimal harm, patternCorrected Sep 11, 2025
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 Sep 11, 2025