Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity H of L: actual harm, patternFound during a complaint inspectionCorrected Mar 10, 2026
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Mar 10, 2026
Provide a written emergency evacuation plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
Meet other general requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 8, 2026
Implement emergency and standby power systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
Establish staff and initial training requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
Establish emergency prep training and testing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
Develop Emergency Preparedness policies and procedures.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
Provide and implement an infection prevention and control program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Mar 10, 2026
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Mar 10, 2026
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
Post nurse staffing information every day.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 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 Mar 10, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 10, 2026
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 Mar 10, 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 Mar 10, 2026
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, patternCorrected Mar 10, 2026
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 inspectionCorrected Mar 10, 2026
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Mar 10, 2026
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 10, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 10, 2026
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 Mar 10, 2026
Reasonably accommodate the needs and preferences of each resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 10, 2026
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 10, 2026
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 10, 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, isolatedCorrected Mar 10, 2026
Keep residents' personal and medical records private and confidential.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 10, 2026
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 Mar 10, 2026
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 inspectionCorrected Mar 10, 2026
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Mar 10, 2026
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Mar 10, 2026
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 Mar 10, 2026
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 10, 2026
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, isolatedFound during a complaint inspectionCorrected Mar 10, 2026
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 10, 2026
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 10, 2026
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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 10, 2026
Have properly installed electrical wiring and gas equipment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 10, 2026