Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected May 29, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Severity L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected May 29, 2024
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 L of L: immediate jeopardy, widespreadFound during a complaint inspectionCorrected May 29, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity J of L: immediate jeopardy, isolatedFound during a complaint inspectionCorrected May 29, 2024
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Severity I of L: actual harm, widespreadFound during a complaint inspectionCorrected Sep 16, 2024
Provide enough food/fluids to maintain a resident's health.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Sep 16, 2024
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Jul 17, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity G of L: actual harm, isolatedFound during a complaint inspectionCorrected Jul 17, 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, widespreadFound during a complaint inspectionCorrected May 29, 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, widespreadFound during a complaint inspectionCorrected Sep 16, 2024
Keep all essential equipment working safely.
Severity F of L: no actual harm, potential for more than minimal harm, widespreadFound during a complaint inspectionCorrected Sep 16, 2024
Keep residents' personal and medical records private and confidential.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected Sep 16, 2024
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity E of L: no actual harm, potential for more than minimal harm, patternFound during a complaint inspectionCorrected May 29, 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 D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected May 29, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected Jul 17, 2024
Reasonably accommodate the needs and preferences of each resident.
Severity D of L: no actual harm, potential for more than minimal harm, isolatedFound during a complaint inspectionCorrected May 29, 2024