| 2025-05-08 | F0658, F0761, F0880, F0883, F0887 | Ensure services provided by the nursing facility meet professional standards of quality. / 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 and implement an infection prevention and control program. / 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. | E |
| 2025-05-08 | F0684, F0699, F0812 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide care or services that was trauma informed and/or culturally competent. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D |
| 2025-04-29 | F0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2024-07-24 | F0658, F0842 | Ensure services provided by the nursing facility meet professional standards of quality. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2024-05-21 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D |
| 2024-03-19 | F0580, F0689, F0692 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / 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. | H |
| 2024-03-19 | F0656, F0686 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G |
| 2024-03-19 | F0679, F0680, F0838 | Provide activities to meet all resident's needs. / Ensure the activities program is directed by a qualified professional. / 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. | F |
| 2024-03-19 | F0550, F0565, F0658, F0812, 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 organize and participate in resident/family groups in the facility. / Ensure services provided by the nursing facility meet professional standards of quality. / 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. | E |
| 2024-03-19 | F0554, F0604, F0655, F0657, F0688, F0690, F0695, F0698, F0756, F0761, F0806, F0849, F0883, F0887 | Allow residents to self-administer drugs if determined clinically appropriate. / Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / 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 a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. / 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. / Provide safe, appropriate dialysis care/services 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. / 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. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. / 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. / 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. | D |
| 2024-03-19 | F0641, F0944 | Ensure each resident receives an accurate assessment. / Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. | B |
| 2023-09-20 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E |
| 2023-09-20 | F0561, F0727, F0755 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / 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. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D |
| 2022-08-24 | F0689, F0692 | 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. | H |
| 2022-08-24 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G |
| 2022-08-24 | F0725, F0726, F0812, F0838, F0882 | 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 nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / 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. / Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F |
| 2022-08-24 | F0657, F0658, F0758, F0804, F0880, F0886 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Ensure services provided by the nursing facility meet professional standards of quality. / 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 food and drink is palatable, attractive, and at a safe and appetizing temperature. / Provide and implement an infection prevention and control program. / Perform COVID19 testing on residents and staff. | E |
| 2022-08-24 | F0550, F0551, F0552, F0656, F0688, F0744, F0761, F0770, F0806, F0842 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Give the resident's representative the ability to exercise the resident's rights. / Ensure that residents are fully informed and understand their health status, care and treatments. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / 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. / Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. / 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. / 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. | D |