Provide safe, appropriate pain management for a resident who requires such services.
Severity G of L: actual harm, isolatedCorrected Jan 24, 2024
Have a plan that describes the process for conducting QAPI and QAA activities.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 24, 2024
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 24, 2024
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 Jan 24, 2024
Provide training in compliance and ethics.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadCorrected Jan 24, 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 Jan 24, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 24, 2024
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 24, 2024
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 E of L: no actual harm, potential for more than minimal harm, patternCorrected Feb 9, 2024
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 24, 2024
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 24, 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 Jan 24, 2024
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Severity E of L: no actual harm, potential for more than minimal harm, patternCorrected Jan 24, 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 Jan 24, 2024
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 Jan 24, 2024
Provide care or services that was trauma informed and/or culturally competent.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 24, 2024
Provide or get specialized rehabilitative services as required for a resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 24, 2024
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 7, 2024
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Jan 24, 2024
Install properly constructed and protected linen or trash chutes.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 6, 2024
Install emergency lighting that can last at least 1 1/2 hours.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedCorrected Feb 5, 2024
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Severity C of L: potential for minimal harm, widespreadCorrected Jan 24, 2024
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity B of L: potential for minimal harm, patternCorrected Jan 24, 2024
Assure that each resident’s assessment is updated at least once every 3 months.
Severity B of L: potential for minimal harm, patternCorrected Jan 24, 2024
Ensure each resident receives an accurate assessment.
Severity B of L: potential for minimal harm, patternCorrected Jan 24, 2024
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Severity B of L: potential for minimal harm, patternCorrected Jan 24, 2024
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Severity B of L: potential for minimal harm, patternCorrected Jan 24, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity B of L: potential for minimal harm, patternCorrected Jan 24, 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 24, 2024
