| 2025-08-26 | F0578, F0605, F0628, F0644, F0656, F0657, F0684, F0690, F0695, F0727, F0812, F0880, F0912 | 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. / Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. / Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. / 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. / 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 and appropriate respiratory care for a resident when needed. / 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. / 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. / Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | D |
| 2024-10-02 | F0656, F0757, F0758, F0812, F0912 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | D |
| 2023-09-22 | F0760 | Ensure that residents are free from significant medication errors. | G |
| 2023-09-22 | F0809, F0812 | 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F |
| 2023-09-22 | F0835, F0880, F0881, F0882 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. / Provide and implement an infection prevention and control program. / Implement a program that monitors antibiotic use. / Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | E |
| 2023-09-22 | F0580, F0609, F0641, F0644, F0656, F0689, F0690, F0725, F0727, F0730, F0732, F0761, F0842, F0867, F0883, F0887, F0912, F0921 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Ensure each resident receives an accurate assessment. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / 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 enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / 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. / Observe each nurse aide's job performance and give regular training. / Post nurse staffing information every day. / 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. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / 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. / Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D |