| 2026-04-01 | 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. | H |
| 2026-04-01 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | G |
| 2026-04-01 | F0880 | Provide and implement an infection prevention and control program. | D |
| 2025-10-17 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G |
| 2025-10-17 | F0604 | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D |
| 2025-09-02 | F0760 | Ensure that residents are free from significant medication errors. | G |
| 2025-07-17 | F0689, F0725, F0761, F0883 | 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. / 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. / Develop and implement policies and procedures for flu and pneumonia vaccinations. | E |
| 2025-07-17 | F0550, F0697, F0887 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Provide safe, appropriate pain management for a resident who requires such services. / 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 |
| 2024-08-12 | F0609, F0610, F0656 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D |
| 2024-04-24 | F0880 | Provide and implement an infection prevention and control program. | F |
| 2024-04-24 | F0561, F0657, F0699, F0725, F0726, F0758 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. / 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 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. / 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. / 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. | E |
| 2024-04-24 | F0655, F0684, F0697, F0609 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Provide safe, appropriate pain management for a resident who requires such services. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D |
| 2023-04-05 | F0657, F0689 | 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. | D |
| 2023-04-05 | 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 | C |