Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity K of L: immediate jeopardy, patternCorrected May 12, 2026
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 12, 2026
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 12, 2026
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 Apr 29, 2026
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 12, 2026
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 12, 2026
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 12, 2026
Honor the resident's right to organize and participate in resident/family groups in the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 12, 2026
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, patternFound during a complaint inspectionCorrected May 12, 2026
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 12, 2026
Provide enough food/fluids to maintain a resident's health.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 12, 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 May 12, 2026
Observe each nurse aide's job performance and give regular training.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 12, 2026
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 12, 2026
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 12, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected May 12, 2026
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 29, 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 29, 2026
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 12, 2026
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 29, 2026
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 29, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 29, 2026
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 12, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 12, 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 May 12, 2026
Install emergency lighting that can last at least 1 1/2 hours.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Severity C of L: potential for minimal harm, widespreadCorrected May 12, 2026
Have generator or other power source capable of supplying service within 10 seconds.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
Have simulated fire drills held at unexpected times.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
Provide properly protected cooking facilities.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
Have properly located and lighted "Exit" signs.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
Establish staff and initial training requirements.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
List the names and contact information of those in the facility.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
Address patient/client population and determine types of services needed.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
Conduct risk assessment and an All-Hazards approach.
Severity C of L: potential for minimal harm, widespreadCorrected Apr 29, 2026
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Severity B of L: potential for minimal harm, patternCorrected May 12, 2026