Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity J of L: immediate jeopardy, isolatedCorrected Jul 25, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Aug 8, 2024
Develop and maintain an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jul 31, 2024
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 8, 2024
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 8, 2024
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 8, 2024
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 8, 2024
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 8, 2024
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 8, 2024
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 8, 2024
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 8, 2024
Provide training in compliance and ethics.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Aug 8, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 8, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Aug 8, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 8, 2024
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 Aug 8, 2024
Assess the resident when there is a significant change in condition
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 8, 2024
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 8, 2024
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 Aug 8, 2024
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, isolatedFound during a complaint inspectionCorrected Aug 8, 2024
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, isolatedFound during a complaint inspectionCorrected Aug 8, 2024
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, isolatedFound during a complaint inspectionCorrected Aug 8, 2024
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 Aug 8, 2024
Ensure medication error rates are not 5 percent or greater.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Aug 8, 2024
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Severity C of L: potential for minimal harm, widespreadCorrected Aug 8, 2024
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 C of L: potential for minimal harm, widespreadCorrected Aug 8, 2024
