Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity H of L: actual harm, patternFound during a complaint inspectionCorrected Jan 10, 2026
Install proper backup exit lighting.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 20, 2026
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 20, 2026
Include a process for Emergency Preparedness collaboration.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 20, 2026
Have exits that are accessible at all times.
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 20, 2026
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 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 Feb 20, 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 Feb 20, 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 20, 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 20, 2026
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 23, 2026
Install a fire alarm system that can be heard throughout the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 20, 2026
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 20, 2026
Observe each nurse aide's job performance and give regular training.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 20, 2026
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 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 Feb 20, 2026
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 20, 2026
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 20, 2026
Have properly installed electrical wiring and gas equipment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 20, 2026
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Mar 13, 2026
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, widespreadCorrected Feb 20, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Feb 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 20, 2026
Provide or get specialized rehabilitative services as required for a resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 20, 2026
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 20, 2026
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Feb 20, 2026
Respond appropriately to all alleged violations.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 20, 2026
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 Feb 20, 2026
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 20, 2026
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, isolatedFound during a complaint inspectionCorrected Feb 20, 2026
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 Feb 20, 2026
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 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 Feb 20, 2026
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 Feb 20, 2026