Establish policies and procedures including evacuation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 4, 2026
Address subsistence needs for staff and patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 4, 2026
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 4, 2026
Have proper medical gas storage and administration areas.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Dec 19, 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 20, 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 Dec 22, 2025
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 16, 2026
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 11, 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 Jan 4, 2026
Implement emergency and standby power systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 4, 2026
Establish policies and procedures for sheltering.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 4, 2026
List the names and contact information of those in the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 4, 2026
Install a fire alarm system that can be heard throughout the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 19, 2025
Have approved installation, maintenance and testing program for fire alarm systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 4, 2026
Have properly installed electrical wiring and gas equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 22, 2025
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 4, 2026
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 2, 2026
Provide emergency officials' contact information.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 4, 2026
Conduct risk assessment and an All-Hazards approach.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 26, 2026
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 17, 2025
Meet requirements for the installation and maintenance of electrical systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 19, 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 Dec 17, 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 Dec 17, 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 Dec 17, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 17, 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 Dec 17, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 17, 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 Dec 17, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 17, 2025
Provide a written emergency evacuation plan.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 4, 2026