Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity K of L: immediate jeopardy, patternFound during a complaint inspectionDeficient, 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 K of L: immediate jeopardy, patternFound during a complaint inspectionDeficient, Provider has no plan of correction
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionDeficient, Provider has no plan of correction
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionPast Non-Compliance
Establish staff and initial training requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 4, 2026
Conduct testing and exercise requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 4, 2026
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 Jun 4, 2026
Install an approved automatic sprinkler system.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 4, 2026
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 Jun 4, 2026
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 4, 2026
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionDeficient, Provider has no plan of correction
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity E of L: no actual harm, potential for more than minimal harm, patternDeficient, Provider has no plan of correction
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionDeficient, Provider has no plan of correction
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionDeficient, Provider has no plan of correction
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionDeficient, Provider has no plan of correction
Inspect, test, and maintain automatic sprinkler systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jun 4, 2026
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 D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionDeficient, Provider has no plan of correction
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionDeficient, Provider has no plan of correction
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 inspectionDeficient, Provider has no plan of correction
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 inspectionPast Non-Compliance
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionPast Non-Compliance
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedDeficient, Provider has no plan of correction
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 4, 2026
Have horizontal exits used in accordance with safety requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 4, 2026
Provide properly protected cooking facilities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 4, 2026
Have properly installed electrical wiring and gas equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 4, 2026
Have simulated fire drills held at unexpected times.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 4, 2026
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 4, 2026
Ensure proper usage of power strips and extension cords.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jun 4, 2026
Post nurse staffing information every day.
Severity C of L: potential for minimal harm, widespreadDeficient, Provider has no plan of correction