| 2026-06-17 | 0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F |
| 2026-06-17 | 0641 | Ensure each resident receives an accurate assessment. | E |
| 2026-06-17 | 0712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. | E |
| 2026-06-17 | 0552 | Ensure that residents are fully informed and understand their health status, care and treatments. | D |
| 2026-06-17 | 0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D |
| 2026-06-17 | 0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D |
| 2026-06-17 | 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D |
| 2026-06-17 | 0695 | Provide safe and appropriate respiratory care for a resident when needed. | D |
| 2026-06-17 | 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2025-04-30 | 0638 | Assure that each resident’s assessment is updated at least once every 3 months. | E |
| 2025-04-30 | 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E |
| 2025-04-30 | 0695 | Provide safe and appropriate respiratory care for a resident when needed. | E |
| 2025-04-30 | 0758 | 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 |
| 2025-04-30 | 0760 | Ensure that residents are free from significant medication errors. | E |
| 2025-04-30 | 0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D |
| 2024-03-13 | 0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F |
| 2024-03-13 | 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E |
| 2024-03-13 | 0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | E |