Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 22, 2026
Establish roles under a Waiver declared by secretary.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 22, 2026
Provide primary/alternate means for communication.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 22, 2026
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 22, 2026
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 22, 2026
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 22, 2026
Have proper power supply for life support equipment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadDeficient, Provider has plan of correction
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 Apr 22, 2026
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 22, 2026
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 22, 2026
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 22, 2026
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Severity E of L: no actual harm, potential for more than minimal harm, patternDeficient, Provider has plan of correction
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 22, 2026
Have exits that are accessible at all times.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 22, 2026
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 Apr 22, 2026
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 22, 2026
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 Apr 22, 2026
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, isolatedCorrected Apr 22, 2026
