Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Severity K of L: immediate jeopardy, patternCorrected Jan 6, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity K of L: immediate jeopardy, patternCorrected Jan 6, 2025
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity K of L: immediate jeopardy, patternCorrected Feb 7, 2025
Respond appropriately to all alleged violations.
Severity H of L: actual harm, patternCorrected Feb 7, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity H of L: actual harm, patternCorrected Feb 7, 2025
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity H of L: actual harm, patternCorrected Feb 7, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity H of L: actual harm, patternCorrected Jan 9, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity G of L: actual harm, isolatedCorrected Jan 6, 2025
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 7, 2025
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 10, 2025
Provide training in compliance and ethics.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 6, 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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 7, 2025
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 6, 2025
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 10, 2025
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 F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Feb 7, 2025
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 10, 2025
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 10, 2025
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 10, 2025
Provide and implement an infection prevention and control program.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 18, 2025
Implement a program that monitors antibiotic use.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 7, 2025
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 3, 2025
Ensure each resident receives an accurate assessment.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 3, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 7, 2025
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Dec 13, 2024
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 6, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 3, 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, patternCorrected Feb 7, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 10, 2025
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 6, 2025
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 6, 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 Jan 6, 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, isolatedCorrected Jan 6, 2025
Have generator or other power source capable of supplying service within 10 seconds.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 13, 2024
Install an approved automatic sprinkler system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 13, 2024
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Dec 13, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 7, 2025
Give the resident's representative the ability to exercise the resident's rights.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 6, 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 Feb 7, 2025
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 7, 2025
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 6, 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 Feb 18, 2025
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, isolatedCorrected Jan 3, 2025
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 3, 2025
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 3, 2025
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 9, 2025
Inspect, test, and maintain automatic sprinkler systems.
Severity C of L: potential for minimal harm, widespreadCorrected Dec 13, 2024
Post nurse staffing information every day.
Severity C of L: potential for minimal harm, widespreadCorrected Jan 6, 2025
Develop and maintain an Emergency Preparedness Program (EP).
Severity C of L: potential for minimal harm, widespreadCorrected Dec 13, 2024
Establish emergency prep training and testing.
Severity C of L: potential for minimal harm, widespreadCorrected Dec 13, 2024
Develop a communication plan.
Severity C of L: potential for minimal harm, widespreadCorrected Dec 13, 2024
Develop Emergency Preparedness policies and procedures.
Severity C of L: potential for minimal harm, widespreadCorrected Dec 13, 2024
Provide properly protected cooking facilities.
Severity B of L: potential for minimal harm, patternCorrected Dec 13, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity B of L: potential for minimal harm, patternCorrected Jan 6, 2025
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity B of L: potential for minimal harm, patternCorrected Jan 3, 2025