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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 9, 2025
Have properly located and lighted "Exit" signs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 9, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 9, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 10, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 10, 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 Jul 10, 2025
Provide enough food/fluids to maintain a resident's health.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 10, 2025
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, patternCorrected Jul 10, 2025
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 10, 2025
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 10, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 10, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 10, 2025
Have approved installation, maintenance and testing program for fire alarm systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 9, 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 Jul 10, 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 Jul 10, 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 Jul 10, 2025
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 Jul 10, 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 Jul 10, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 10, 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 Jul 10, 2025
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 10, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 10, 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 Jul 10, 2025
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 10, 2025
