Health inspection·April 30, 2018

Citations

19 citations recorded^*CMS

• 0578GeneralS&S Bno actual harm

  F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

• 0582GeneralS&S Bno actual harm

  F582 - The facility must—

  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

• 0623GeneralS&S Bno actual harm

  F623 - Transfer and discharge-

  Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

• 0625GeneralS&S Bno actual harm

  F625 - Transfer and discharge-

  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.

• 0640GeneralS&S Bno actual harm

  F640 - Automated data processing requirement-

  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

• 0641GeneralS&S Bno actual harm

  F641 - Accuracy of Assessments

  Ensure each resident receives an accurate assessment.

• 0655GeneralS&S Bno actual harm

  F655 - Comprehensive Person-Centered Care Planning

  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

• 0656GeneralS&S Dpotential for harm

  F656 - Comprehensive Care Plans

  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

• 0684GeneralS&S Dpotential for harm

  F684 - Quality of care

  Provide appropriate treatment and care according to orders, resident’s preferences and goals.

• 0697GeneralS&S Dpotential for harm

  F697 - Pain Management

  Provide safe, appropriate pain management for a resident who requires such services.

• 0730GeneralS&S Cno actual harm

  F730 - Regular in-service education

  Observe each nurse aide's job performance and give regular training.

• 0756GeneralS&S Epotential for harm

  F756 - Drug Regimen Review

  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

• 0758GeneralS&S Epotential for harm

  F758 - Medication Errors

  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.

• 0838GeneralS&S Cno actual harm

  F838 - Facility assessment

  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.

• 0841GeneralS&S Cno actual harm

  F841 - Medical director

  Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

• 0867GeneralS&S Fpotential for harm

  F867 - Program feedback, data systems and monitoring

  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

• 0868GeneralS&S Cno actual harm

  F868 - Quality assessment and assurance

  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

• 0880GeneralS&S Epotential for harm

  F880 - Infection Control

  Provide and implement an infection prevention and control program.

• 0947GeneralS&S Cno actual harm

  F947 - Training Requirements

  Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.