Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Aug 26, 2025
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Aug 26, 2025
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 Aug 26, 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 Aug 26, 2025
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 Aug 26, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 26, 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 Aug 26, 2025
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 26, 2025
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Sep 11, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 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 Aug 26, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 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 Aug 26, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 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 Aug 26, 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 Aug 26, 2025
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 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, isolatedFound during a complaint inspectionCorrected Aug 26, 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 D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 2025
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 2025
Provide activities to meet all resident's needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 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 Aug 26, 2025
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 Aug 26, 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 Aug 26, 2025
Provide enough food/fluids to maintain a resident's health.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 2025
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 Aug 26, 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 Aug 26, 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 Aug 26, 2025
Ensure that residents are free from significant medication errors.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 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, isolatedFound during a complaint inspectionCorrected Aug 26, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 2025
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 2025
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 2025
Properly select, install, inspect, or maintain portable fire extinguishes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 26, 2025
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Severity C of L: potential for minimal harm, widespreadCorrected Aug 26, 2025