| 2026-06-05 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E |
| 2025-03-05 | F0727, F0882 | 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. / Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F |
| 2025-03-05 | F0585, F0655, F0657, F0677, F0686, F0803, F0804, F0881 | 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. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / 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 pressure ulcer care and prevent new ulcers from developing. / 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. / Implement a program that monitors antibiotic use. | E |
| 2025-03-05 | F0550, F0623, F0625, F0641, F0645, F0656, F0658, F0660, F0684, F0688, F0745 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / 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. / Ensure each resident receives an accurate assessment. / PASARR screening for Mental disorders or Intellectual Disabilities / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure services provided by the nursing facility meet professional standards of quality. / Plan the resident's discharge to meet the resident's goals and needs. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / 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 medically-related social services to help each resident achieve the highest possible quality of life. | D |
| 2024-11-07 | F0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | D |
| 2023-12-12 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G |
| 2023-12-12 | F0623, F0625, F0801, F0802, F0812 | 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. / 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. / Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F |
| 2023-12-12 | F0584, F0657, F0728, F0730, F0842, F0880, F0881 | 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 that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. / 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. / Implement a program that monitors antibiotic use. | E |
| 2023-12-12 | F0552, F0585, F0637, F0641, F0645, F0658, F0677, F0685, F0686, F0689, F0690, F0692, F0698, F0726, F0727, F0758, F0759, F0804, F0806, F0825 | Ensure that residents are fully informed and understand their health status, care and treatments. / 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. / Assess the resident when there is a significant change in condition / 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 care and assistance to perform activities of daily living for any resident who is unable. / Assist a resident in gaining access to vision and hearing services. / 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 appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. / Provide enough food/fluids to maintain a resident's health. / Provide safe, appropriate dialysis care/services for a resident who requires such services. / 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 registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. / 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. / Ensure medication error rates are not 5 percent or greater. / Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. / Provide or get specialized rehabilitative services as required for a resident. | D |
| 2023-12-12 | F0732 | Post nurse staffing information every day. | B |
| 2023-10-04 | F0600, F0689, F0699 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide care or services that was trauma informed and/or culturally competent. | G |
| 2023-10-04 | F0607, F0725, F0732, F0835, F0837, F0838, F0843, F0865, F0882, F0940 | Develop and implement policies and procedures to prevent abuse, neglect, and theft. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / Post nurse staffing information every day. / 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. / 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. / 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. / Have a plan that describes the process for conducting QAPI and QAA activities. / Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. / Develop, implement, and/or maintain an effective training program for all new and existing staff members. | F |
| 2023-10-04 | F0610, F0686, F0726, F0729, F0758, F0947 | Respond appropriately to all alleged violations. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / 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. / Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. / 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. / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | E |
| 2022-08-12 | F0812, F0865, F0880, F0887 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Have a plan that describes the process for conducting QAPI and QAA activities. / 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. | F |
| 2022-08-12 | F0550, F0610, F0641, F0645, F0658, F0660, F0686, F0692, F0725, F0726, F0758, F0881, F0885, F0886 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Respond appropriately to all alleged violations. / 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. / Plan the resident's discharge to meet the resident's goals and needs. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide enough food/fluids to maintain a resident's health. / 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. / Implement a program that monitors antibiotic use. / Report COVID19 data to residents and families. / Perform COVID19 testing on residents and staff. | E |
| 2022-08-12 | F0578, F0657, F0677, F0688, F0689, F0745, F0759, F0761, F0791, 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. / 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 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. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide medically-related social services to help each resident achieve the highest possible quality of life. / Ensure medication error rates are not 5 percent or greater. / 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 or obtain dental services for each resident. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |