| 2025-06-18 | F0835, F0837, F0865, F0867, F0880, F0881 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. / 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. / Have a plan that describes the process for conducting QAPI and QAA activities. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. / Provide and implement an infection prevention and control program. / Implement a program that monitors antibiotic use. | F |
| 2025-06-18 | F0761 | 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. | E |
| 2025-06-18 | F0550, F0609, F0656, F0658, F0684, F0688, F0692, F0699, F0759, F0842, F0883, F0887 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure services provided by the nursing facility meet professional standards of quality. / 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. / Provide enough food/fluids to maintain a resident's health. / Provide care or services that was trauma informed and/or culturally competent. / Ensure medication error rates are not 5 percent or greater. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / 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 |
| 2024-07-11 | F0692, F0773 | Provide enough food/fluids to maintain a resident's health. / Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | G |
| 2024-07-11 | F0658 | Ensure services provided by the nursing facility meet professional standards of quality. | E |
| 2023-12-12 | F0568 | Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | D |
| 2023-05-03 | F0760 | Ensure that residents are free from significant medication errors. | H |
| 2023-05-03 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G |
| 2023-05-03 | F0584, F0636, F0730, F0761, F0835, F0865, F0867, F0925 | 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. / Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. / Observe each nurse aide's job performance and give regular training. / 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. / Administer the facility in a manner that enables it to use its resources effectively and efficiently. / Have a plan that describes the process for conducting QAPI and QAA activities. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. / Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | F |
| 2023-05-03 | F0656, F0679, F0759, F0804, F0812, F0842 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide activities to meet all resident's needs. / Ensure medication error rates are not 5 percent or greater. / Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E |
| 2023-05-03 | F0552, F0585, F0609, F0610, F0638, F0641, F0658, F0676, F0677, F0684, F0687, F0693, F0695, F0698, F0725, F0726, F0791, F0881, F0947 | Ensure that residents are fully informed and understand their health status, care and treatments. / 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Assure that each resident’s assessment is updated at least once every 3 months. / Ensure each resident receives an accurate assessment. / Ensure services provided by the nursing facility meet professional standards of quality. / Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate foot care. / 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 dialysis care/services for a resident who requires such services. / 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. / Provide or obtain dental services for each resident. / Implement a program that monitors antibiotic use. / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D |