Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 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 30, 2025
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2025
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 30, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 22, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 22, 2025
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 22, 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 Sep 22, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 22, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 22, 2025
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 22, 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 22, 2025
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 22, 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 Sep 22, 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 Sep 22, 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 22, 2025
Provide properly protected cooking facilities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 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, isolatedCorrected Sep 22, 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 Sep 22, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 22, 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 22, 2025
Provide appropriate foot care.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 22, 2025
Install properly constructed and protected linen or trash chutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2025
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 22, 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 22, 2025
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 22, 2025
Ensure medical gas and vacuum systems have documented maintenance programs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 30, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Severity B of L: potential for minimal harm, patternCorrected Sep 22, 2025