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 25, 2026
Keep all essential equipment working safely.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 11, 2026
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 Mar 11, 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 Feb 25, 2026
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 11, 2026
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, patternFound during a complaint inspectionCorrected Mar 11, 2026
Provide care or services that was trauma informed and/or culturally competent.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 11, 2026
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 11, 2026
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 11, 2026
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 11, 2026
Reasonably accommodate the needs and preferences of each resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Mar 11, 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 Mar 11, 2026
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Mar 11, 2026
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 Mar 11, 2026
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 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 Mar 11, 2026
Provide routine and 24-hour emergency dental care for each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 2026
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 2026
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 2026
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 2026
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 2026
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 2026
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 Mar 11, 2026
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 2026
Provide training in compliance and ethics.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 2026
Protect each resident from the wrongful use of the resident's belongings or money.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 11, 2026
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Severity C of L: potential for minimal harm, widespreadCorrected Mar 11, 2026
Meet other general requirements.
Severity C of L: potential for minimal harm, widespreadCorrected Feb 25, 2026
Develop and maintain an Emergency Preparedness Program (EP).
Severity C of L: potential for minimal harm, widespreadCorrected Feb 25, 2026
Have generator or other power source capable of supplying service within 10 seconds.
Severity C of L: potential for minimal harm, widespreadCorrected Feb 25, 2026
Have simulated fire drills held at unexpected times.
Severity C of L: potential for minimal harm, widespreadCorrected Feb 25, 2026
Install emergency lighting that can last at least 1 1/2 hours.
Severity C of L: potential for minimal harm, widespreadCorrected Feb 25, 2026
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity B of L: potential for minimal harm, patternCorrected Feb 25, 2026