Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity J of L: immediate jeopardy, isolatedCorrected May 20, 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 May 20, 2026
Establish policies and procedures for medical documentation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Establish policies and procedures including evacuation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Establish procedures for tracking staff and patients during an emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Address subsistence needs for staff and patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Develop Emergency Preparedness policies and procedures.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Address patient/client population and determine types of services needed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 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 May 20, 2026
Create arrangements with other facilities to receive patients.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Establish emergency prep training and testing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Establish staff and initial training requirements.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Ensure that testing and maintenance of electrical equipment is performed.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Develop a communication plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 20, 2026
Have generator or other power source capable of supplying service within 10 seconds.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2026
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 May 20, 2026
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 May 20, 2026
Give residents a notice of rights, rules, services and charges.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2026
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 2026
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 May 20, 2026
PASARR screening for Mental disorders or Intellectual Disabilities
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 20, 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, patternCorrected May 20, 2026
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 May 20, 2026
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 20, 2026
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected May 20, 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 May 20, 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 May 20, 2026
Provide safe and appropriate respiratory care for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 20, 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 May 20, 2026
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 20, 2026
Ensure services provided by the nursing facility meet professional standards of quality.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 20, 2026
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity C of L: potential for minimal harm, widespreadCorrected May 20, 2026