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.
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 2025-10-30.Deficient, Provider has date of correction