Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected Apr 10, 2026
Have a plan that describes the process for conducting QAPI and QAA activities.
Severity L of L: immediate jeopardy, widespreadCorrected Apr 10, 2026
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity L of L: immediate jeopardy, widespreadCorrected Apr 10, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity K of L: immediate jeopardy, patternFound during a complaint inspectionCorrected Apr 10, 2026
Protect each resident from the wrongful use of the resident's belongings or money.
Severity K of L: immediate jeopardy, patternFound during a complaint inspectionCorrected Apr 10, 2026
Inspect, test, and maintain automatic sprinkler systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 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 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
Install emergency lighting that can last at least 1 1/2 hours.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
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 Apr 10, 2026
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Meet requirements for the installation and maintenance of electrical systems.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Apr 10, 2026
Have proper medical gas storage and administration areas.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 10, 2026
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 10, 2026
Ensure medication error rates are not 5 percent or greater.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 10, 2026
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 10, 2026
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 10, 2026
Have power receptacles that are properly grounded.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Apr 10, 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, isolatedFound during a complaint inspectionCorrected Apr 10, 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 Apr 10, 2026
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Apr 10, 2026
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, isolatedFound during a complaint inspectionCorrected Apr 10, 2026