| 2026-04-02 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E |
| 2026-04-02 | F0550, F0561, F0607, F0609, F0610, F0730, F0842, F0880 | 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. / 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. / 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. | D |
| 2025-04-03 | F0814, F0868 | Dispose of garbage and refuse properly. / Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F |
| 2025-04-03 | F0550, F0580, F0656, F0657, F0684, F0725, F0803, F0804, F0812, F0842, F0880 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / 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 appropriate treatment and care according to orders, resident’s preferences and goals. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / 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. / 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. / Provide and implement an infection prevention and control program. | E |
| 2025-04-03 | F0558, F0584, F0622, F0641, F0686, F0689, F0883 | Reasonably accommodate the needs and preferences of each 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. / 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. / 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. / Develop and implement policies and procedures for flu and pneumonia vaccinations. | D |
| 2024-10-08 | F0609, F0656, F0684, F0756 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / 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. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D |
| 2024-04-02 | F0584, F0679, F0680, F0689 | 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. / Provide activities to meet all resident's needs. / Ensure the activities program is directed by a qualified professional. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E |
| 2024-02-14 | F0600, F0607, F0609, F0610 | 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. | K |
| 2024-02-14 | F0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. | H |
| 2024-02-14 | F0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E |
| 2024-02-14 | F0655, F0684, F0842 | 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. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2023-04-11 | F0585, F0623, F0625, F0656, F0684, F0726, F0730, F0732, F0755, F0756, F0758, F0812, F0868, 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 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. / 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. / 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. / Observe each nurse aide's job performance and give regular training. / Post nurse staffing information every day. / 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. / 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. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Have the Quality Assessment and Assurance group have the required members and meet at least quarterly / Provide and implement an infection prevention and control program. | E |
| 2023-04-11 | F0550, F0609, F0636, F0641, F0657, F0686, F0689, F0842 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / 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. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |