Implement a program that monitors antibiotic use.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 15, 2025
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 15, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 15, 2025
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 F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Oct 15, 2025
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 15, 2025
Implement emergency and standby power systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Oct 15, 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 Oct 15, 2025
Have properly installed electrical wiring and gas equipment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 15, 2025
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 15, 2025
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 15, 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 E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Oct 15, 2025
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Oct 15, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 15, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 15, 2025
Use approved construction type or materials.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 15, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 6, 2026
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Oct 15, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 15, 2025
Ensure that residents are free from significant medication errors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 15, 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 Oct 15, 2025
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 15, 2025
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 15, 2025
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 15, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 15, 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, isolatedCorrected Oct 15, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Oct 15, 2025
Protect each resident from the wrongful use of the resident's belongings or money.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 15, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Oct 15, 2025
