| 2024-07-16 | F0726, F0865 | 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. / Have a plan that describes the process for conducting QAPI and QAA activities. | F |
| 2024-07-16 | F0578, F0623, F0625, F0677, F0684, F0689, F0880, F0940 | 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. / 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. / 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. / 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. / Develop, implement, and/or maintain an effective training program for all new and existing staff members. | E |
| 2024-07-16 | F0584, F0657, F0658, F0688, F0755, F0756, F0757, F0760, F0770, F0773, F0775, F0842, F0883, F0887 | 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 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. / 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 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 each resident’s drug regimen must be free from unnecessary drugs. / Ensure that residents are free from significant medication errors. / Provide timely, quality laboratory services/tests to meet the needs of residents. / 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. / 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 |
| 2024-03-29 | F0760, F0867 | Ensure that residents are free from significant medication errors. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | G |
| 2024-03-29 | F0726 | 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. | F |
| 2024-03-29 | F0558, F0600, F0607, F0623, F0625, F0677, F0684, F0689, F0725, F0730, F0755, F0756, F0880, F0887, F0940, F0941, F0942, F0943, F0944, F0947, F0949, F0578 | Reasonably accommodate the needs and preferences of each resident. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Develop and implement policies and procedures to prevent abuse, neglect, and theft. / 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. / 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / 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. / 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. / Provide and implement an infection prevention and control program. / 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. / Develop, implement, and/or maintain an effective training program for all new and existing staff members. / Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. / Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. / Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. / Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. / Provide behavior health training consistent with the requirements and as determined by a facility assessment. / 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. | E |
| 2024-03-29 | F0550, F0561, F0580, F0584, F0636, F0641, F0656, F0657, F0658, F0676, F0679, F0686, F0688, F0692, F0697, F0757, F0773, F0842, F0865, F0883, F0770, F0775 | 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 and the facility must promote and facilitate resident self-determination through support of resident choice. / Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / 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. / Ensure each resident receives an accurate assessment. / 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. / 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 activities to meet all resident's needs. / 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 enough food/fluids to maintain a resident's health. / Provide safe, appropriate pain management for a resident who requires such services. / Ensure each resident’s drug regimen must be free from unnecessary drugs. / Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. / Have a plan that describes the process for conducting QAPI and QAA activities. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / Provide timely, quality laboratory services/tests to meet the needs of residents. / Keep complete, dated laboratory records in the resident's record. | D |
| 2024-03-29 | F0575, F0577 | Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. / Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | C |
| 2023-11-01 | 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. | F |
| 2023-11-01 | F0584, F0689, F0755 | 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E |
| 2023-11-01 | F0655, F0656, F0657, F0658, F0686, F0687, F0692, F0759, F0760, F0842, F0880 | 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. / 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. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide appropriate foot care. / Provide enough food/fluids to maintain a resident's health. / Ensure medication error rates are not 5 percent or greater. / Ensure that residents are free from significant medication errors. / 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 |
| 2023-08-16 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G |
| 2023-08-16 | F0609, F0684 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2022-07-19 | F0578, F0609, F0625, F0641, F0645, F0658, F0684, F0689, F0692, F0695, F0755, F0756, F0761, F0842 | 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / 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. / Ensure each resident receives an accurate assessment. / PASARR screening for Mental disorders or Intellectual Disabilities / 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. / 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 and appropriate respiratory care 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. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2021-08-05 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G |
| 2021-08-05 | F0656, F0657, F0677, F0684, F0919 | 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 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. / Make sure that a working call system is available in each resident's bathroom and bathing area. | E |
| 2021-08-05 | F0607, F0609, F0610, F0622, F0641, F0645, F0690, F0691, F0692, F0693, F0695, F0697, F0698, F0756, F0761, F0772, F0842, F0883 | 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. / Respond appropriately to all alleged violations. / 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 each resident receives an accurate assessment. / PASARR screening for Mental disorders or Intellectual Disabilities / 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 appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. / Provide enough food/fluids to maintain a resident's health. / 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 pain management for a resident who requires such services. / 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. / Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. / 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. | D |