Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 30, 2025
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 30, 2025
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 Jul 18, 2025
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 Jul 18, 2025
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jun 30, 2025
Observe each nurse aide's job performance and give regular training.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 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 Jul 18, 2025
Provide or obtain dental services for each resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 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 Jul 18, 2025
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 Jul 18, 2025
Provide activities to meet all resident's needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jul 18, 2025
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 Jul 18, 2025
Assess the resident when there is a significant change in condition
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 18, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 18, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 18, 2025
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 18, 2025
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 18, 2025
Assure that each resident’s assessment is updated at least once every 3 months.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 18, 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 Jul 18, 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 Jul 18, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jul 18, 2025