Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
No actual harm occurred, but a finding has the potential for more than minimal harm if uncorrected.
CMS uses a scope/severity grid (A through L). Letters A-F indicate no actual harm, G-I indicate actual harm, and J-L indicate immediate jeopardy. Scope (isolated, pattern, widespread) is encoded in the same letter.
Corrected on 2025-05-30.Deficient, Provider has date of correction