| 2026-05-11 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K |
| 2026-05-11 | F0760 | Ensure that residents are free from significant medication errors. | J |
| 2026-05-11 | F0600, F0677, F0689 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G |
| 2026-05-11 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | E |
| 2026-05-11 | F0550, F0561, F0580, F0583, F0610, F0656, F0695, F0761, F0770, F0777, F0842, F0865, F0880 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Keep residents' personal and medical records private and confidential. / Respond appropriately to all alleged violations. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide safe and appropriate respiratory care for a resident when needed. / 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. / Provide timely, quality laboratory services/tests to meet the needs of residents. / Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Have a plan that describes the process for conducting QAPI and QAA activities. / Provide and implement an infection prevention and control program. | D |
| 2025-12-04 | F0550, F0880 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Provide and implement an infection prevention and control program. | E |
| 2025-12-04 | F0557, F0635, F0641, F0644, F0677, F0679, F0686, F0691, F0692, F0698, F0757, F0770, F0791 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. / Provide doctor's orders for the resident's immediate care at the time the resident was admitted. / Ensure each resident receives an accurate assessment. / Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide activities to meet all resident's needs. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. / Provide enough food/fluids to maintain a resident's health. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / Provide timely, quality laboratory services/tests to meet the needs of residents. / Provide or obtain dental services for each resident. | D |
| 2025-12-04 | F0574 | The resident has the right to receive notices in a format and a language he or she understands. | C |
| 2024-10-02 | F0686, F0760 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that residents are free from significant medication errors. | G |
| 2024-10-02 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F |
| 2024-10-02 | F0656, F0657, F0690, F0849, F0880, F0887 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. / Provide and implement an infection prevention and control program. / Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | E |
| 2024-10-02 | F0552, F0561, F0641, F0684, F0688, F0689, F0692, F0693, F0695, F0697, F0732, F0757, F0807, F0883, F0921 | Ensure that residents are fully informed and understand their health status, care and treatments. / Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / Ensure each resident receives an accurate assessment. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide enough food/fluids to maintain a resident's health. / Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. / Provide safe and appropriate respiratory care for a resident when needed. / Provide safe, appropriate pain management for a resident who requires such services. / Post nurse staffing information every day. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D |
| 2024-10-02 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | B |
| 2024-04-10 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J |
| 2024-04-10 | F0580, F0686, F0690, F0838 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / 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. | D |
| 2024-04-10 | F0837 | 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. | C |
| 2023-08-10 | F0725, F0760 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / Ensure that residents are free from significant medication errors. | K |
| 2023-08-10 | F0635, F0695 | Provide doctor's orders for the resident's immediate care at the time the resident was admitted. / Provide safe and appropriate respiratory care for a resident when needed. | J |
| 2023-08-10 | F0686, F0692 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide enough food/fluids to maintain a resident's health. | G |
| 2023-08-10 | F0812, F0880, F0908 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide and implement an infection prevention and control program. / Keep all essential equipment working safely. | F |
| 2023-08-10 | F0578, F0584, F0585, F0600, F0657, F0684, F0690, F0697, F0756, F0868, F0947 | 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. / 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. / 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. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Provide safe, appropriate pain management for a resident who requires such services. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / Have the Quality Assessment and Assurance group have the required members and meet at least quarterly / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E |
| 2023-08-10 | F0550, F0562, F0580, F0603, F0610, F0644, F0656, F0677, F0685, F0688, F0689, F0693, F0758, F0803, F0806, F0842, F0882, F0923, F0940, F0942, F0943, F0944, F0946, F0949 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Provide immediate access to any resident. / Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). / Respond appropriately to all alleged violations. / Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Assist a resident in gaining access to vision and hearing services. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. / 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. / 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. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. / Have enough outside ventilation via a window or mechanical ventilation, or both. / Develop, implement, and/or maintain an effective training program for all new and existing staff members. / Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. / Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. / Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. / Provide training in compliance and ethics. / Provide behavior health training consistent with the requirements and as determined by a facility assessment. | D |