Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 30, 2025
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 30, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 30, 2025
Address subsistence needs for staff and patients.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Establish policies and procedures for volunteers.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Establish roles under a Waiver declared by secretary.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Provide primary/alternate means for communication.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Provide a means of sharing information on occupancy/needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Provide family notifications of emergency plan.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Establish staff and initial training requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Conduct testing and exercise requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 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 13, 2025
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Have generator or other power source capable of supplying service within 10 seconds.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Ensure that testing and maintenance of electrical equipment is performed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Develop and maintain an Emergency Preparedness Program (EP).
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
Conduct risk assessment and an All-Hazards approach.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 13, 2025
