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 Feb 28, 2026
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 28, 2026
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 28, 2026
Establish staff and initial training requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 27, 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 Mar 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 Feb 27, 2026
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 27, 2026
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 Feb 28, 2026
Ensure services provided by the nursing facility meet professional standards of quality.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 28, 2026
Keep all essential equipment working safely.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 28, 2026
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 Feb 28, 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 Feb 28, 2026
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2026
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2026
Install corridor and hallway doors that block smoke.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2026
Have proper medical gas storage and administration areas.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 27, 2026
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 Feb 28, 2026
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 28, 2026
Have simulated fire drills held at unexpected times.
Severity C of L: potential for minimal harm, widespreadCorrected Feb 27, 2026
