Address subsistence needs for staff and patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
Establish policies and procedures for volunteers.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
Develop a communication plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
Include a process for Emergency Preparedness collaboration.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
Ensure that testing and maintenance of electrical equipment is performed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
List the names and contact information of those in the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
Provide emergency officials' contact information.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
Provide a means of sharing information on occupancy/needs.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
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 Aug 5, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 5, 2025
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 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 Aug 5, 2025
Establish policies and procedures including evacuation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 14, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 4, 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 Aug 4, 2025
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 14, 2025
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 4, 2025
Install an approved automatic sprinkler system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 14, 2025
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 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 Aug 4, 2025
Provide or get specialized rehabilitative services as required for a resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 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 Aug 4, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 2025
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 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 Aug 4, 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, isolatedFound during a complaint inspectionCorrected Aug 4, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 2025
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 4, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Aug 4, 2025
Have properly installed hallway dispensers for alcohol-based hand rub.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 14, 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 Jul 14, 2025