| 2025-02-03 | F0656, F0689, F0758, F0880 | 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. / 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. / Provide and implement an infection prevention and control program. | E |
| 2025-02-03 | F0622, F0658, F0690, F0693, F0694, F0755, F0756, F0761 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. / Ensure services provided by the nursing facility meet professional standards of quality. / 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 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 for the safe, appropriate administration of IV fluids for a resident when needed. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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. | D |
| 2024-01-11 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G |
| 2024-01-11 | F0880 | Provide and implement an infection prevention and control program. | F |
| 2024-01-11 | F0550, F0801, F0804, F0812, F0842, F0881 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. / 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. / Implement a program that monitors antibiotic use. | E |
| 2024-01-11 | F0692, F0761, F0779, F0805, F0806, F0811, F0689 | Provide enough food/fluids to maintain a resident's health. / 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. / Keep signed and dated reports of x-rays and other diagnostic services in the residents record. / Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. / Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D |
| 2022-04-13 | F0600, F0609, F0610, F0684, F0689 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | K |
| 2022-04-13 | F0686, F0740 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | J |
| 2022-04-13 | F0692, F0697, F0725, F0726, F0741, F0745, F0835, F0837, F0841, F0865, F0867, F0868 | Provide enough food/fluids to maintain a resident's health. / Provide safe, appropriate pain management 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. / Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. / Provide medically-related social services to help each resident achieve the highest possible quality of life. / 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. / Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in 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. / Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | H |
| 2022-04-13 | F0580, F0644, F0688, F0710, F0742, F0770 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. / 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. / Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. / 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. / Provide timely, quality laboratory services/tests to meet the needs of residents. | G |
| 2022-04-13 | F0727, F0838, F0880, F0882, F0908, F0943, F0947 | 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. / 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. / Provide and implement an infection prevention and control program. / Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. / Keep all essential equipment working safely. / Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | F |
| 2022-04-13 | F0550, F0565, F0567, F0568, F0584, F0585, F0606, F0608, F0655, F0656, F0660, F0677, F0755, F0761, F0804, F0842, F0886, F0887, F0888, F0919, F0921 | 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. / Honor the resident's right to manage his or her financial affairs. / Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. / 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. / 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. / Not hire anyone with a finding of abuse, neglect, exploitation, or theft. / Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. / 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. / 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 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. / Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Perform COVID19 testing on residents and staff. / 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. / Ensure staff are vaccinated for COVID-19 / Make sure that a working call system is available in each resident's bathroom and bathing area. / Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E |
| 2022-04-13 | F0558, F0561, F0578, F0582, F0622, F0645, F0685, F0690, F0695, F0698, F0732, F0757, F0760, F0773, F0775, F0779, F0825, F0881 | Reasonably accommodate the needs and preferences of each resident. / 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. / Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. / Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. / PASARR screening for Mental disorders or Intellectual Disabilities / Assist a resident in gaining access to vision and hearing services. / 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. / Post nurse staffing information every day. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / Ensure that residents are free from significant medication errors. / Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. / Keep complete, dated laboratory records in the resident's record. / Keep signed and dated reports of x-rays and other diagnostic services in the residents record. / Provide or get specialized rehabilitative services as required for a resident. / Implement a program that monitors antibiotic use. | D |