Develop Emergency Preparedness policies and procedures.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 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 Apr 10, 2026
Have simulated fire drills held at unexpected times.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Have approved installation, maintenance and testing program for fire alarm systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Provide properly protected cooking facilities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Have an enclosure around a vertical opening shaft.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Establish emergency prep training and testing.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Develop a communication plan.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Have generator or other power source capable of supplying service within 10 seconds.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 28, 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 Apr 10, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 27, 2026
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 27, 2026
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 27, 2026
Respond appropriately to all alleged violations.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 27, 2026
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 27, 2026
Implement a program that monitors antibiotic use.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Mar 27, 2026
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 Mar 27, 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 Mar 27, 2026
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 27, 2026
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 27, 2026
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Mar 27, 2026