| 2026-06-04 | F0628, F0742, F0842 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. / Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2026-01-29 | F0551 | Give the resident's representative the ability to exercise the resident's rights. | D |
| 2025-03-24 | F0584, F0656, F0695, F0699, F0725, F0755, F0761, F0814, F0842, F0867, F0880 | 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. / 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. / Provide care or services that was trauma informed and/or culturally competent. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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. / Dispose of garbage and refuse properly. / 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. / Provide and implement an infection prevention and control program. | E |
| 2025-03-24 | F0578, F0644, F0657, F0689, F0758 | 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. / Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / 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. | D |
| 2025-03-24 | F0623, F0625 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | B |
| 2024-05-29 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K |
| 2024-05-29 | F0865, F0868, F0921, F0941, F0944, F0946 | Have a plan that describes the process for conducting QAPI and QAA activities. / Have the Quality Assessment and Assurance group have the required members and meet at least quarterly / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. / Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. / Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. / Provide training in compliance and ethics. | E |
| 2024-05-29 | F0557, F0558, F0626, F0646, F0656, F0842, F0843, F0880, F0949 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. / Reasonably accommodate the needs and preferences of each resident. / Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. / Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. / Provide and implement an infection prevention and control program. / Provide behavior health training consistent with the requirements and as determined by a facility assessment. | D |
| 2024-02-27 | F0880 | Provide and implement an infection prevention and control program. | E |
| 2024-02-01 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F |
| 2024-02-01 | F0584, F0655, F0679, F0725, F0730, F0842, F0880, F0908 | 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. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Provide activities to meet all resident's needs. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / Observe each nurse aide's job performance and give regular training. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Provide and implement an infection prevention and control program. / Keep all essential equipment working safely. | E |
| 2024-02-01 | F0656, F0689, F0692, F0698, F0947 | 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 enough food/fluids to maintain a resident's health. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D |
| 2024-02-01 | F0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | B |
| 2022-03-17 | F0584, F0880 | 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. / Provide and implement an infection prevention and control program. | E |
| 2022-03-17 | F0607, F0609, F0656, F0657, F0684, F0810, F0812 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. / 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. / 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 special eating equipment and utensils for residents who need them and appropriate assistance. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D |