| 2026-06-05 | F0584, F0607, F0627, F0677, F0693 | 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 policies and procedures to prevent abuse, neglect, and theft. / Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. / Provide care and assistance to perform activities of daily living for any resident who is unable. / 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. | D |
| 2026-03-20 | F0583, F0609 | Keep residents' personal and medical records private and confidential. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D |
| 2026-03-06 | 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. | D |
| 2026-03-04 | F0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D |
| 2025-12-31 | F0676, F0684 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2025-04-24 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2025-03-28 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G |
| 2025-03-28 | F0865, F0868 | 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 | E |
| 2025-03-28 | F0554, F0561, F0565, F0600, F0604, F0609, F0657, F0677, F0684, F0694, F0700, F0800, F0842, F0880 | Allow residents to self-administer drugs if determined clinically appropriate. / Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / Honor the resident's right to organize and participate in resident/family groups in the facility. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / 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 for the safe, appropriate administration of IV fluids for a resident when needed. / Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. / Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. / 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. | D |
| 2024-12-06 | F0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F |
| 2024-12-06 | F0585, F0635, F0660, F0677, F0684, F0686, F0689, F0880 | 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. / Provide doctor's orders for the resident's immediate care at the time the resident was admitted. / Plan the resident's discharge to meet the resident's goals and needs. / 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 pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide and implement an infection prevention and control program. | D |
| 2024-02-09 | F0689, F0761, F0880 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / 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. | E |
| 2024-02-09 | F0655, F0656, F0684, F0686, F0688, F0690, F0700, F0745, F0812, F0849 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / 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. / Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. / Provide medically-related social services to help each resident achieve the highest possible quality of life. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / 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. | D |
| 2023-11-01 | F0580, F0655, F0656, F0684, F0686, F0689, F0697, F0755 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide safe, appropriate pain management for a resident who requires such services. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D |
| 2022-11-18 | F0684, F0690, F0712, F0773, F0803, F0804, F0883 | 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. / Ensure that the resident and his/her doctor meet face-to-face at all required visits. / Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. / 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 food and drink is palatable, attractive, and at a safe and appetizing temperature. / Develop and implement policies and procedures for flu and pneumonia vaccinations. | D |