Establish an Emergency Preparedness Program (EP).
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected May 28, 2025
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, widespreadFound during a complaint inspectionCorrected May 30, 2025
Have a plan that describes the process for conducting QAPI and QAA activities.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected May 30, 2025
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, patternFound during a complaint inspectionCorrected May 30, 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 E of L: no actual harm, potential for more than minimal harm, patternCorrected May 30, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 30, 2025
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 2025
Protect each resident from the wrongful use of the resident's belongings or money.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected May 30, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected May 30, 2025
Respond appropriately to all alleged violations.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected May 30, 2025
Ensure each resident receives an accurate assessment.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 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, isolatedCorrected May 30, 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 May 30, 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, isolatedFound during a complaint inspectionCorrected May 30, 2025
Provide and implement an infection prevention and control program.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 2025
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected May 30, 2025
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 May 30, 2025