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 Mar 12, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 12, 2025
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 12, 2025
Establish emergency prep training and testing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 12, 2025
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, widespreadDeficient, Provider has no plan of correction
Meet requirements for sections of health care facilities separated by fire resistive construction.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadDeficient, Provider has no plan of correction
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 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 Mar 12, 2025
Keep all essential equipment working safely.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Have properly located and lighted "Exit" signs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Severity E of L: no actual harm, potential for more than minimal harm, patternDeficient, Provider has no plan of correction
Use approved construction type or materials.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 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 Mar 12, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 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 Mar 12, 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, patternDeficient, Provider has no plan of correction
Install corridor and hallway doors that block smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Install an approved automatic sprinkler system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
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, patternDeficient, Provider has no plan of correction
Have an enclosure around a vertical opening shaft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Have exits that are accessible at all times.
Severity E of L: no actual harm, potential for more than minimal harm, patternDeficient, Provider has no plan of correction
Conform to length requirements for dead end corridors.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
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, patternCorrected Mar 12, 2025
Assure the security of all personal funds of residents deposited with the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Give residents a notice of rights, rules, services and charges.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
The resident has the right to receive notices in a format and a language he or she understands.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
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 Mar 12, 2025
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Have power receptacles that are properly grounded.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 12, 2025
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 12, 2025
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 12, 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, isolatedCorrected Mar 12, 2025
Assist a resident in gaining access to vision and hearing services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 12, 2025
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 12, 2025
Install emergency lighting that can last at least 1 1/2 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 12, 2025