Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected Sep 16, 2025
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 7, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Sep 16, 2025
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 16, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 16, 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 Sep 16, 2025
Have proper medical gas storage and administration areas.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 7, 2025
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Sep 16, 2025
Meet requirements for the installation and maintenance of electrical systems.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 7, 2025
Ensure proper usage of power strips and extension cords.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 7, 2025
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 16, 2025
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 7, 2025
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 7, 2025
Provide properly protected cooking facilities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 7, 2025
Have an enclosure around a vertical opening shaft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 7, 2025
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 7, 2025
Install a two-hour-resistant firewall separation.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 7, 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 Sep 16, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 16, 2025
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Provide care or services that was trauma informed and/or culturally competent.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
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, isolatedCorrected Sep 16, 2025
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 Sep 16, 2025
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Dispose of garbage and refuse properly.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 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 Sep 16, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Provide training in compliance and ethics.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 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 Sep 16, 2025
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, isolatedCorrected Sep 16, 2025
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, isolatedCorrected Sep 16, 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 Sep 16, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Protect a residents' right to refuse some types of non-requested transfers within the nursing home.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Sep 16, 2025
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Sep 16, 2025
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 16, 2025
Meet other general requirements.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 7, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Sep 7, 2025
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 Sep 16, 2025
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 Sep 16, 2025
Meet other general requirements.
Severity C of L: potential for minimal harm, widespreadCorrected Sep 7, 2025
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 B of L: potential for minimal harm, patternCorrected Sep 7, 2025
