🔎 Mescalero Care Center

Scope/Severity: E

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Scope/Severity: E

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Scope/Severity: E

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Scope/Severity: E

Ensure each resident receives an accurate assessment.

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity: E

Provide activities to meet all resident's needs.

Scope/Severity: E

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Scope/Severity: E

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

Scope/Severity: E

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

Scope/Severity: E

Provide or obtain dental services for each resident.

Scope/Severity: F

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity: E

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Scope/Severity: E

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Scope/Severity: E

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Scope/Severity: E

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Scope/Severity: E

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

Scope/Severity: E

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Scope/Severity: E

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.

Scope/Severity: E

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Scope/Severity: F

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.

Scope/Severity: E

Provide or obtain dental services for each resident.

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity: F

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

Scope/Severity: F

Provide and implement an infection prevention and control program.

Scope/Severity: E

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Scope/Severity: E

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Scope/Severity: E

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

Scope/Severity: E

Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity: F

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Scope/Severity: F

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.

Scope/Severity: F

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

Scope/Severity: E

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Scope/Severity: E

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.

Scope/Severity: E

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.

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity: F

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Scope/Severity: F

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

Scope/Severity: E

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Scope/Severity: E

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

Scope/Severity: E

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.

Scope/Severity: E

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

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Scope/Severity: E

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.

Scope/Severity: E

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.

Scope/Severity: E

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.

Scope/Severity: F

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity: F

Provide and implement an infection prevention and control program.

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Scope/Severity: F

Ensure staff are vaccinated for COVID-19

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Scope/Severity: E

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Scope/Severity: F

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Scope/Severity: F

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

Scope/Severity: E

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

Scope/Severity: F

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Scope/Severity: F

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

Scope/Severity: F

Provide and implement an infection prevention and control program.

Scope/Severity: F

Implement a program that monitors antibiotic use.

Scope/Severity: F

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Scope/Severity: F

The resident has the right to receive notices in a format and a language he or she understands.

Scope/Severity: F

Ensure residents have reasonable access to and privacy in their use of communication methods.

Scope/Severity: F

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Scope/Severity: E

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Scope/Severity: E

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Scope/Severity: E

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

Scope/Severity: E

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.

Scope/Severity: E

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Scope/Severity: F

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Scope/Severity: F

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

Scope/Severity: F

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Scope/Severity: E

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Scope/Severity: E

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.

Scope/Severity: E

Ensure medication error rates are not 5 percent or greater.

Scope/Severity: E

Provide or obtain dental services for each resident.

Scope/Severity: F

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity: F

Have a plan that describes the process for conducting QAPI and QAA activities.

Scope/Severity: F

Provide and implement an infection prevention and control program.

Scope/Severity: F

Implement a program that monitors antibiotic use.

Scope/Severity: E

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Scope/Severity: F

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.