Nursing Home Administrator Study Guide 2026–2027

Only after proper notice and when the resident has failed to pay. Discharge is generally inappropriate when payment is delayed by a pending Medicaid or Medicare process.

No. It may ask a person with legal access to the resident's funds to agree to pay from those funds, but that person is not personally liable.

No. Arbitration agreements must be voluntary, explained in plain language and may not be a condition of admission or continued stay.

No. Time in observation or the emergency department is outpatient status and does not count, so confirm inpatient status.

Plans often require prior authorization and may waive the 3-day stay. Verify authorization and coverage rules with each plan before admitting.

Explain the risks, offer alternatives and referrals, ask the resident to sign the AMA form, and document any refusal to sign.

The right to appeal to the state agency designated for hearings. The notice must state how and by when to appeal.

A resident who needs nursing services must be readmitted to the first available bed in a semi-private room, even after bed-hold days end.

Medication reconciliation, home health and equipment arrangements, follow-up appointments, teaching of the resident and caregivers with teach-back, and a clear written plan.

Physician orders, history and physical, PASRR, TB screening and immunization history, advance directives, consents, financial forms and an inventory of belongings.

A process that involves the resident and representative, evaluates goals, caregiver capacity and needs, arranges services and gives a post-discharge plan of care.

State level-of-care approval, PASRR screening and financial eligibility.

Review of the referral, hospital records and clinical needs, payer source and the facility's ability to meet the person's needs before agreeing to admit.

Contact information, advance directives and code status, special instructions, infection status, medication list, comprehensive care plan goals and the facility's contact details.

Interventions to Reduce Acute Care Transfers, a quality program with tools such as Stop and Watch, SBAR communication and care paths to catch decline early and avoid hospital transfers.

Participation in assessment and goal setting. It records whether the resident wants to return to the community, leading to a referral to the Local Contact Agency.

A transfer is a move to another institution that is legally responsible for the resident, such as a hospital. A discharge is a move to a non-institutional setting, such as home.

Five years (60 months). Asset transfers for less than fair value in that period can trigger a penalty period during which Medicaid long-term care is not paid.

Medicare Part A covers skilled nursing facility care after at least 3 consecutive inpatient hospital days, not counting the discharge day, with admission to the facility within 30 days.

A notice delivered at least 2 days before Medicare-covered services end. It tells the resident how to request a fast appeal from the Quality Improvement Organization by noon of the day before services end.

A facility may not require a private-pay period before Medicaid, ask for a deposit from Medicaid residents, or charge them differently for covered services.

A form (CMS-10055) given when the facility expects Medicare not to pay for an item or service, such as custodial care. It lets the resident decide whether to receive the care and accept the cost.

A physician-approved temporary absence, such as a family visit. The facility prepares medications and instructions, documents the leave and follows state bed-hold and payment rules.

A recapitulation of the stay, a final summary of the resident's status, a reconciliation of medications and a post-discharge plan of care.

The reason, effective date, destination, appeal rights and contact information, and ombudsman contact details, in a language and manner the resident understands.

Give written notice to the state, residents, representatives and the ombudsman at least 60 days ahead, or as state law requires, and submit a plan to relocate residents safely.

It may not require a resident to waive rights or Medicare or Medicaid benefits, and must not require a third party to guarantee payment.

Their rights and facility rules, services and charges, how to file grievances, the ombudsman contact, how to see survey results, bed-hold policy and advance directive rights.

Residents have the right to notice, with the reason documented, before a room or roommate change, and may share a room with a spouse.

To protect residents and the facility. The facility must safeguard property, keep the list current and investigate any loss or theft.

Stage 1 is non-blanchable redness. Stage 2 is partial-thickness loss. Stage 3 is full-thickness skin loss. Stage 4 is full-thickness loss with exposed bone, tendon or muscle. Others are unstageable and deep tissue injury.

Section D uses the PHQ-9 resident mood interview. A staff assessment version is used when the resident cannot be interviewed.

An unintentional change in position that brings the person to rest on the floor or a lower level, whether or not they are injured.

Scores range from 0 to 15. A score of 13 to 15 means cognitively intact, 8 to 12 moderately impaired, and 0 to 7 severely impaired.

A quarterly assessment at least every 92 days and a comprehensive annual assessment at least every 366 days.

Every 30 days for the first 90 days after admission and at least every 60 days after that. Visits may alternate with a nurse practitioner or physician assistant as allowed.

Assess fall risk on admission and after any fall, review medications, set toileting schedules, ensure proper footwear and lighting, provide exercise and therapy, and avoid using restraints as a solution.

Skin inspection, repositioning on a schedule set by the care plan, pressure-redistributing surfaces, moisture management, adequate nutrition and hydration, and heel offloading.

Post no-smoking and oxygen signs, keep flames and heat sources away, secure cylinders upright, and follow the physician's order for flow rate.

Ensure pain control meets professional standards and the care plan, using non-drug approaches as well as medication, and respect the resident's goals and preferences.

Implement resident care policies, coordinate medical care, and help the facility with quality assurance and infection control. The medical director works with the administrator but does not report to them clinically.

An entry tracking record is completed on admission or reentry. A discharge assessment is completed when a resident leaves, either return anticipated or not anticipated, and a death in facility record is completed at death.

5% in one month, 7.5% in three months, or 10% in six months. It should trigger assessment and a care plan response.

Routine and emergency dental services as needed, including help with appointments and transport. If dentures are lost or damaged, a referral must be made within 3 days.

Functional abilities and goals in self-care and mobility. It feeds PDPM function scores and quality reporting.

Care and services to maintain or improve ADLs, such as bathing, dressing, eating, toileting and mobility, unless decline is unavoidable because of the resident's condition.

Assist residents in getting eye and hearing exams, eyeglasses and hearing aids, and in repairing or replacing them.

An initial plan developed within 48 hours of admission that includes initial goals, physician orders, dietary orders, therapy, social services and PASRR recommendations.

A comprehensive reassessment done when a resident has a major decline or improvement that will not resolve on its own. It must be completed within 14 days of determining the change.

Preadmission Screening and Resident Review. It screens for serious mental illness and intellectual disability before admission to a Medicaid-certified facility, with a Level I screen and a Level II evaluation when needed.

A nursing program that helps residents maintain or improve function, such as walking, range of motion, dressing and eating skills. It follows the care plan and is documented.

The last day of the look-back period that an MDS assessment covers. The interdisciplinary team sets it so the assessment captures the right observation window.

A pressure injury risk tool scoring sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Lower scores mean higher risk, and 18 or below is commonly treated as at risk.

A review of MDS responses that trigger potential problem areas, used to decide which need further assessment and care planning.

A standardized assessment of each resident's health, function, strengths and needs. It drives care planning, Medicare payment and quality measures.

The Medicare Part A skilled nursing payment model effective October 1, 2019. It pays based on resident characteristics across PT, OT, SLP, nursing and non-therapy ancillary components, not therapy minutes.

The federally required process for assessing residents, made up of the MDS 3.0, the Care Area Assessment process and the RAI User's Manual guidelines.

Keep the environment as free of accident hazards as possible and provide each resident with adequate supervision and assistive devices to prevent accidents.

Coordinate with the dialysis facility, share information on transfers, monitor the access site and ensure care meets professional standards.

When the resident cannot lower them or get out of bed voluntarily. Use requires assessment, entrapment risk review, informed consent and the least restrictive approach.

When it develops despite evaluation of the resident's condition and risk factors, defined goals and interventions that fit the resident's needs, and monitoring and revision of the approach.

Only when the resident's clinical condition shows it is necessary. The facility must assess, document the reason and try to remove it when possible.

Only when the resident's clinical condition shows it is necessary. The facility must also work to restore the resident's ability to eat when possible.

Within 14 days after the assessment completion date, through the state's MDS submission system.

By day 14 of the resident's stay.

After each assessment, by the interdisciplinary team, to reflect the resident's current goals and needs.

Within 7 days after completion of the comprehensive assessment.

Immediately for an accident with injury, a significant change in condition, a need to change treatment significantly, or a decision to transfer or discharge.

The 5-day PPS assessment, with an ARD in the first 8 days of the stay, plus the optional Interim Payment Assessment (IPA). The 14-, 30-, 60- and 90-day PPS assessments were eliminated.

The attending physician, the registered nurse responsible for the resident, a nurse aide, a food and nutrition staff member, other disciplines as needed, and the resident and representative.

Offer memorial services, counseling and chaplain support, allow time for goodbyes, and recognize the emotional toll on caregivers.

Delirium has a sudden onset, fluctuating attention and is often reversible. Dementia is gradual and progressive. Report any sudden mental status change right away.

Record what happened, the time, possible triggers, interventions tried and the response. The care plan is updated as the picture changes.

Screen using the PHQ-9 in the MDS, assess for causes, involve the physician and mental health professionals, use therapy and medications as appropriate, and increase meaningful social contact.

Respect privacy and the right to relationships, assess capacity to consent, protect against abuse or exploitation, and reflect decisions in the care plan.

Separate and protect the residents, assess for injury, notify the physician and families, report and investigate as possible abuse, and revise care plans.

Address unmet needs, adjust seating, lighting and routine, use low beds and sensor alarms where appropriate, increase supervision and offer meaningful activity.

Routine home care, continuous home care, inpatient respite care and general inpatient care.

Early (mild) with memory lapses, middle (moderate) with confusion and need for help with daily tasks, and late (severe) with total care needs and loss of communication.

Alzheimer's disease, vascular dementia, Lewy body dementia and frontotemporal dementia. Mixed dementia combines more than one type.

A physician certifies a terminal illness with a life expectancy of six months or less if the disease runs its normal course, and the resident elects hospice care.

Approach from the front, use the resident's name, speak simply and slowly, give one instruction at a time, allow time, and respond to feelings rather than correcting.

Facilities must provide training on dementia management and resident abuse prevention as part of required staff education, appropriate to each role.

The facility must have enough qualified staff with the right skills to give behavioral health care, and must meet residents' mental, emotional and psychosocial needs.

The resident has serious mental illness or an intellectual disability needing evaluation. The facility incorporates the findings into the care plan and works with the state on needed services.

The resident gives up Medicare coverage for treatment aimed at curing the terminal illness and related conditions, but can revoke the election at any time.

A decline in memory, thinking and function that interferes with daily life. Alzheimer's disease is the most common cause, accounting for roughly 60 to 80% of cases.

A resident leaves the facility unsafely without supervision. Assess risk on admission, use alarms and supervision as care planned, keep identification current and review incidents.

A written agreement between the facility and the hospice. The hospice manages the terminal illness care, the facility provides room, board and personal care, and both follow a coordinated care plan.

Increased confusion and agitation in the late afternoon or evening. Helpful approaches include steady routines, good lighting, quiet evenings and avoiding overstimulation.

Describe the behavior, Investigate causes, Create a plan, and Evaluate results. It is a structured way to find and address triggers.

Palliative care relieves symptoms and can be given at any stage of serious illness with curative treatment. Hospice is comfort-focused care for people with a terminal prognosis.

Older adults with dementia-related psychosis who take antipsychotics have an increased risk of death. These drugs are not approved for dementia-related behaviors.

Care that recognizes past trauma, such as war experience or abuse, identifies triggers, avoids retraumatizing practices and builds trust. Federal rules require it.

Notify the physician and representative, follow state and local rules for release of the body, inventory and return belongings, and convey the resident's funds within 30 days as the rules require.

Validation, reminiscence, Montessori-based activities and Namaste care. All start with the resident's history, abilities and preferences.

Disclosure of unit features and consent, safety and elopement protections, staff dementia training, meaningful activity and compliance with state law.

Stay with the resident, remove hazards, notify the nurse and physician at once, arrange a mental health evaluation, and update the care plan and supervision level.

Look for causes such as pain or unmet needs, adjust the environment and routine, and use individualized non-drug approaches like music, activity and calm communication.

Staff must know and honour the resident's wishes in an emergency. Orders such as DNR must be visible, consistent across records and reviewed when wishes or conditions change.

Range-of-motion exercise, proper positioning, splints when ordered, mobility programs and timely therapy referral.

Physical therapy addresses strength, mobility and balance. Occupational therapy addresses daily living skills and fine motor function. Speech-language pathology addresses communication, cognition and swallowing.

Assess on admission, weigh on a schedule, review intake and preferences, and use fortified foods, supplements and feeding help when weight or intake drops.

Section F records preferences such as wake time, bathing, music, reading and religious activities. The care plan then reflects them.

By heat, with a final rinse at about 180 degrees F or the machine maker's setting, or by chemicals used at the concentration on the label. Test and record results.

About 1,500 mL a day is a common baseline, adjusted for each resident's condition and orders. The facility must provide enough fluid to prevent dehydration.

Provide voter registration help, absentee ballot access, transportation or on-site voting, and privacy. Do not influence the resident's choices.

Non-nursing staff who complete a state-approved course of at least 8 hours and help residents without complex feeding problems under the supervision of a nurse.

Coughing or choking with meals, a wet or gurgly voice, food pocketing, drooling, repeated chest infections and weight loss. Refer for a swallowing evaluation.

Address residents' psychosocial needs, support adjustment to admission, plan discharge, help with advance directives, advocate, support families and help prevent abuse.

Hazard Analysis and Critical Control Points. Identify hazards, set critical control points and limits, monitor, take corrective action, verify, and keep records.

A qualified dietitian or other clinically qualified nutrition professional full-time, part-time or by consultant. If not full-time, a certified director of food and nutrition services must run the department.

A person-centered program based on assessment and the care plan that supports independence, includes options for residents with dementia or who are bedbound, and is led by a qualified professional.

Buy from approved sources, store dry goods off the floor, use first in first out, label and date items, and discard ready-to-eat refrigerated food after 7 days.

At least three meals a day at regular times. No more than 14 hours between a substantial evening meal and breakfast, or up to 16 hours if a bedtime snack is offered.

Keep cold foods at 41 degrees F or below and hot foods at 135 degrees F or above. The danger zone is between 41 and 135 degrees F.

Medicare coverage of skilled care depends on the need for skilled services, not on whether the resident is likely to improve. Skilled maintenance therapy can be covered.

Evaluates swallowing, recommends diet textures and liquids and safe feeding strategies, and trains staff. The SLP also treats communication and cognition.

A diet with fewer restrictions, such as less limited sodium or sugar when appropriate. It helps intake, preferences and quality of life in older residents.

The International Dysphagia Diet Standardisation Initiative, a global scale of levels 0 to 7 that describes food textures and drink thickness for people with swallowing problems.

Combined group and concurrent therapy is limited to 25% of a resident's therapy minutes in each discipline.

Allow a family council to meet, provide private space and a staff liaison on request, and respond to the group's concerns.

Diagnoses, measurable goals, type, amount, frequency and duration of treatment, and physician certification. It is reviewed and recertified as needed.

Menus that meet residents' nutritional needs, follow the written menu, are prepared in advance, reflect cultural and religious preferences, and are reviewed by the dietitian.

Residents may practice their faith, receive visits from clergy, and have services arranged. Staff must respect beliefs and avoid pressure.

Vaccination and health records, supervision, allergy and infection control checks, resident consent, and areas where animals are not allowed, such as food preparation.

Screening and background checks, orientation on resident rights and confidentiality, defined roles, supervision and infection control training.

Food must be palatable, attractive and served at a safe and appetizing temperature. Residents can request substitutes of similar nutritional value.

Social, spiritual, physical, creative and cognitive activities, outings, intergenerational events and one-to-one in-room visits.

When the facility has more than 120 beds. The social worker should have a bachelor's degree in social work or a related field and a year of healthcare experience.

Employees with vomiting, diarrhea, jaundice or sore throat with fever. Follow the health department rules and facility policy for return to work.

Title VI of the Civil Rights Act, Section 504 of the Rehabilitation Act, the Americans with Disabilities Act, the Age Discrimination Act and Section 1557 of the ACA, covering race, national origin, disability, age and sex.

Physical, occupational and speech therapy and other specialized services when ordered by a physician and needed under the care plan, either directly or through arrangement.

The attending physician, or another qualified professional if state law and facility policy allow. The diet must be on the menu and follow an approved diet manual.

Payment-driven or excessive therapy can lead to false claims and OIG scrutiny. Administrators must oversee medical necessity and keep clinical decisions with therapists.

Net accounts receivable divided by average daily net revenue. Lower is better, and many facilities target about 30 to 45 days.

The SNF Prospective Payment System sets a daily rate adjusted for case mix and local wages. CMS updates the rates each year for the federal fiscal year beginning October 1.

It pays a daily benefit up to a limit after an elimination period, once the policyholder meets benefit triggers. Verify benefits and submit claims with documentation.

Fixed costs divided by the contribution margin per resident day, which is revenue per day minus variable cost per day.

Jointly by the federal government and the state. Medicaid is the largest payer of long-term nursing home care, and each state sets its own rates within federal rules.

Resident days divided by available bed days over a period, shown as a percentage.

Up to 100 days per benefit period. Days 1 to 20 have no coinsurance, days 21 to 100 require a daily coinsurance, and coverage ends after day 100.

The current ratio, which is current assets divided by current liabilities, and days cash on hand, which is cash divided by daily operating expenses.

Segregation of duties, dual signatures, regular bank reconciliations, controlled access to cash and records, and independent review or audit.

Operating margin is operating income divided by revenue. EBITDA is earnings before interest, taxes, depreciation and amortization. EBITDAR also adds back rent and is used for leased facilities.

Redetermination by the contractor, reconsideration by a qualified independent contractor, an administrative law judge hearing, the Medicare Appeals Council and federal court.

The operating budget for revenue and expenses, the capital budget for major purchases, and the cash budget for the timing of receipts and payments.

Verify eligibility and authorization, admit, document and code care, bill, collect payment, work denials and report results.

The balance sheet, where assets equal liabilities plus equity, the income statement and the statement of cash flows.

The SNF Quality Reporting Program applies a 2 percentage point reduction to the facility's annual Medicare payment update for failing to report required data.

A person covered by both Medicare and Medicaid. Medicaid may pay Medicare coinsurance for days 21 to 100, subject to state rules.

A federally insured mortgage for building, buying or refinancing nursing homes and other care facilities, with long terms and fixed rates.

A state assessment on facilities used to draw federal Medicaid matching funds. States often return the funds to facilities through higher rates.

Revenue is recorded when earned and expenses when incurred, regardless of cash timing. It is required by GAAP for most providers.

If a resident is discharged and returns to the same facility within the 3-day interrupted stay window, counted from the day of discharge, the stay is treated as continuous for payment.

Comparing actual results to the budget, labelling differences favorable or unfavorable and investigating the causes to take corrective action.

States must seek repayment of long-term care costs from the estates of Medicaid recipients aged 55 or older, with protections for a surviving spouse or dependent child.

Uncollectible Medicare deductibles and coinsurance that a provider has made reasonable efforts to collect. Medicare reimburses a percentage of allowable bad debt, currently 65% for SNFs.

The part of the resident's income that must go toward the cost of care each month, after allowed deductions such as the personal needs allowance.

The share of resident days paid by each source, such as Medicare, Medicaid, managed care and private pay. It strongly influences revenue and margin.

Total revenue or total cost divided by resident days. They are used to compare performance across periods and facilities.

The facility bills Medicare for nearly all services given to a Part A resident, including therapy and supplies. Outside suppliers are paid by the facility, with limited exclusions such as certain physician services.

A federal law that makes it a crime to offer or accept anything of value to induce referrals of federal health program business, with limited safe harbors.

Net operating income divided by annual debt payments. Lenders usually require a ratio above 1.2 or higher.

Fixed costs, such as rent and insurance, stay the same as census changes. Variable costs, such as food and supplies, change with the number of residents.

A federal law that penalizes knowingly submitting false claims for payment, with treble damages. It allows whistleblowers (qui tam) to sue on behalf of the government.

Labor, which usually accounts for more than half of operating costs. Overtime, agency use and turnover are major cost drivers.

An annual report of costs and statistics that certified providers must file, generally within 5 months after the fiscal year ends. It is used to settle payments.

The non-therapy ancillary component is paid at three times the rate for the first 3 days. The PT and OT components fall by 2% every 7 days beginning on day 21.

A small monthly amount of income that a Medicaid nursing home resident may keep for personal use. The federal minimum is $30 and states may set more.

A Medicare program that withholds a portion of payments and returns incentives to facilities based on performance, such as avoiding potentially preventable readmissions.

A physician orders it, the resident needs daily skilled nursing or skilled rehabilitation, and the care is for a condition treated in the qualifying stay or arising during the SNF stay.

Prospective cost-based rates, flat rates and case-mix-adjusted rates, sometimes with add-ons for quality or special populations.

Spousal impoverishment rules let the community spouse keep a share of resources and a minimum monthly income allowance so the couple is not left destitute.

Rates, authorization requirements, notification rules, timely filing and denials. Track and appeal denials and verify coverage before admission.

State veterans homes, VA community nursing home contracts and the VA Aid and Attendance pension for eligible veterans and surviving spouses.

After the beneficiary has been out of any hospital or skilled nursing facility for 60 consecutive days. A new benefit period then begins with the next inpatient stay.

Custodial care is help with daily activities, such as bathing and dressing, that does not need skilled personnel. Medicare does not cover it when it is the only care needed.

The ICD-10 code assigns the resident's clinical category, which sets PT and OT payment. Inaccurate coding can result in underpayment or an overpayment finding.

To confirm each resident's balance matches the bank, detect errors or theft early, and produce accurate quarterly statements.

It allows physician, specialist and behavioral health visits by video. Ensure privacy, equipment, resident consent and compliance with current payer and state rules.

The period set by state law, or 5 years from discharge if the state has no rule. For minors, 3 years after reaching legal age under state law.

Keep tested offline backups, have a contingency and downtime plan, train staff to spot phishing, and have an incident response plan.

On paper, draw a single line through it, initial and date it. In electronic records, add an addendum. Never erase, hide or alter entries.

Backup paper forms and processes, such as printed medication records and care plans, to keep care safe during an outage, then entry of data after recovery.

Unique user IDs, role-based access, encryption, audit logs, automatic logoff and secure backups.

Notify affected individuals without unreasonable delay and within 60 days of discovery. Notify HHS, and the media if a breach affects over 500 residents of a state.

The Privacy Rule, the Security Rule and the Breach Notification Rule. The HITECH Act strengthened enforcement and penalties.

Timely, accurate, factual, objective, complete, legible and signed with date and time. Late entries are labelled as late.

Residents may ask for corrections to their records and for a list of certain disclosures of their PHI made outside treatment, payment and operations.

Staff must not take or share photos or videos of residents that humiliate or demean them, and any sharing needs consent. Violations can be abuse and a privacy breach.

Administrative, physical and technical safeguards, supported by a required risk analysis and risk management plan.

Identification, admission records, assessments such as the MDS, care plans, physician orders, progress notes, medication and treatment records, test results and discharge information.

Residents may inspect their records within 24 hours of a request, excluding weekends and holidays, and get copies within 2 working days of a request.

A designated privacy officer and security officer, written policies and training for all staff when hired and as policies change.

A document explaining how PHI is used and the resident's rights. Give it at first service, make a good-faith effort to get written acknowledgment and post it.

Interoperability lets different systems share data securely. A health information exchange moves records among providers to improve transitions of care.

Individually identifiable health information, including identifiers like name, address and dates, held or sent by a covered entity or business associate in any form.

A covered entity is a health care provider, plan or clearinghouse. A business associate handles PHI for it and must sign a business associate agreement.

Use, disclose and request only the PHI needed for the purpose. It does not apply to treatment disclosures between providers.

Consent of the resident and roommate, privacy, notice and state law. Some states have electronic monitoring statutes, so follow them and facility policy.

A description of the information, who may disclose it and who will receive it, the purpose, an expiration date, and the resident's signature and date.

For uses and disclosures outside treatment, payment and operations, such as marketing, sale of PHI and psychotherapy notes.

For treatment, payment and health care operations, and for certain public health, legal and oversight purposes allowed by the Privacy Rule.

A person with legal authority to act for the resident, such as a health care agent or guardian. State law and documents decide the scope.

Use labelled biohazard bags and puncture-resistant sharps containers, replace sharps containers when about three-quarters full, and dispose through licensed services under state rules.

Wear protective equipment, absorb the spill, clean with detergent, then disinfect with an EPA-registered product or freshly made bleach solution as policy directs.

Keep chemicals in labelled containers and locked rooms, and keep carts locked or attended so residents with cognitive impairment cannot reach them.

Handle as little as possible, bag it at the point of use without shaking or sorting in resident rooms, and treat all soiled linen as potentially infectious.

Fix leaks quickly, dry affected materials within 24 to 48 hours, replace material that cannot be dried, and follow ICRA controls while remediating.

From clean to dirty and from high to low, so dirt and germs do not spread to cleaned areas.

Hot water at about 160 degrees F for at least 25 minutes, or low-temperature washing with the proper chemicals, following the manufacturer's directions.

Services necessary to keep the interior sanitary, orderly and comfortable for residents, and to maintain the building and equipment in safe condition.

Thorough cleaning and disinfection of a room after a resident leaves or when isolation ends, covering all surfaces, equipment and the bathroom.

One-way from dirty to clean with separate soiled and clean areas. Clean linen is covered and kept away from soiled items.

Bed rails, call buttons, door handles, light switches and handrails. They should be cleaned and disinfected often, at least daily and more during outbreaks.

To prevent loss and mix-ups, protect dignity and reduce complaints. Keep an inventory and a process for lost items.

The label gives approved uses, dilution and the contact (wet) time needed to kill germs. Using it incorrectly reduces effectiveness and can harm staff and residents.

Lint is a major cause of laundry fires. Clean lint traps after each load and have vents and ducts cleaned on schedule.

To prevent cross-contamination between areas such as bathrooms and resident rooms or kitchens.

Assess risks, train staff in de-escalation and dementia care, use reporting systems, support injured staff and review incidents to adjust care plans.

The staffing rating uses PBJ data, including nurse staffing hours, weekend staffing and turnover. Poor staffing can lower the overall star rating.

Employers pay state unemployment taxes and respond to claims. Accurate documentation of the reason for separation helps resolve claims.

Keep personnel files separate from medical and I-9 files, limit access, follow retention requirements and protect confidentiality.

Verify at hire with the issuing board, record expiration dates, monitor renewals and remove staff from duties that need a lapsed credential.

Pre-employment, post-accident, reasonable suspicion and random testing where policy and state law allow. Apply policy consistently.

Report a work-related fatality within 8 hours and a hospitalization, amputation or loss of an eye within 24 hours. Keep injury and illness logs.

Non-exempt employees must be paid at least one and a half times the regular rate for hours over 40 in a workweek, and employers must keep accurate time records.

Written standards, high-level oversight, care in delegating authority, communication and training, monitoring and a reporting system, consistent enforcement and response to violations.

Usually a verbal warning, written warning, suspension and then termination, with documentation and consistent application. Serious misconduct may skip steps.

Halo and horn effects, recency, central tendency and leniency. Clear criteria and regular feedback reduce bias.

Wages, hours and working conditions, a grievance and arbitration process and a management rights clause. Managers must apply it consistently.

Either party may end employment at any time for any lawful reason. Exceptions include discrimination, retaliation, public policy and contract terms.

Employees and families may keep employer group health coverage, at their own cost, for a limited time after events such as job loss, in employers with 20 or more employees.

No discrimination against qualified people with disabilities and reasonable accommodation unless it causes undue hardship. It applies to employers with 15 or more employees.

Workers aged 40 and older from age-based discrimination. It applies to employers with 20 or more employees.

Written disclosure and the applicant's written authorization, a pre-adverse action notice with a copy of the report before rejecting, and a final adverse action notice.

Employees' right to organize and bargain collectively. Employers cannot interfere with, restrain or coerce employees, which would be an unfair labor practice.

Chemical labels, safety data sheets, a written program and staff training so workers know the hazards of chemicals they use.

Employment discrimination based on race, color, religion, sex (including pregnancy and sexual orientation) and national origin. It applies to employers with 15 or more employees.

Assigning the same caregivers to the same residents regularly. It improves relationships, quality of care and staff and resident satisfaction.

Facilities submit direct care staffing hours from payroll data to CMS each quarter, due 45 days after the quarter ends.

Unwelcome conduct that creates a hostile environment or conditions job benefits on compliance. Employers need a clear policy, a complaint process and prompt investigation.

By prior agreement, a 14-day period may be used so overtime is paid for hours over 8 in a day and over 80 in the 14-day period.

Exempt employees meet salary and duties tests and are not owed overtime. Non-exempt employees, including most aides and nurses paid hourly, must receive overtime.

The employee completes Section 1 by the first day of work. The employer completes Section 2 within 3 business days of the start date after examining identity and work authorization documents.

It defines duties, essential functions, qualifications and reporting lines. It guides hiring, evaluation, training and ADA reasonable accommodation decisions.

To state policies and expectations, document acknowledgment, and clarify at-will status. It should be reviewed for legal compliance regularly.

No-fault insurance that pays medical costs and lost wages for work-related injuries. Return-to-work programs and safety efforts help control costs.

Federal law prohibits retaliation against employees who report suspected crimes or abuse, and facilities must inform staff of their reporting rights.

Job boards, employee referrals, partnerships with schools and training programs, community outreach, internal promotion and a strong employer reputation.

Verify licenses and exclusion status, orient to policies and residents, ensure competence, and manage the extra cost. Agency staff must follow the same rules.

Pre-employment health screening, TB testing, hepatitis B and influenza vaccination offers, exposure follow-up and rules for staying home when sick.

Review documentation and policies, check for protected activity, consult human resources or counsel, handle final pay as state law requires, and hold the meeting respectfully.

Resident rights, abuse reporting, infection control, fire and emergency procedures, HIPAA, safety, policies and job duties.

Abuse, neglect and exploitation, resident rights, infection control, dementia care, QAPI, compliance and ethics, and behavioral health, based on role.

Employees who have worked 12 months and 1,250 hours at a site where the employer has 50 or more employees within 75 miles. They may take up to 12 weeks of unpaid, job-protected leave a year.

Lifting and moving residents is a leading cause of staff back injuries. Programs use lifts, training and assessments to reduce injuries.

It raises costs and harms continuity of care. Retention improves with fair pay, career ladders, flexible schedules, recognition, good supervision and consistent assignment.

Federal programs will not pay for services by excluded individuals. Check the OIG exclusion list and state lists at hire and regularly afterward, or risk penalties and repayment.

Base staffing on resident needs and the facility assessment, use data to manage costs, and never reduce care below safe levels to protect margins.

Meet licensure continuing education requirements, earn additional credentials, mentor others, join associations and attend conferences.

Monitor CMS updates, State Operations Manual revisions, the Federal Register and state agency notices, and update policies and training promptly.

Manageable workloads, fair scheduling, recognition, supportive supervision, access to counseling and a safe, respectful workplace.

Transformational leaders inspire a shared vision and development. Transactional leaders rely on rewards, corrections and clear exchanges for performance.

Disclose them, step away from the decision, follow gift and vendor policies and document the resolution.

Duty of care, duty of loyalty and duty of obedience to the mission and the law, all exercised in the best interest of the organization.

Unclear messages, noise, assumptions, hierarchy, cultural and language differences and poor listening. Active listening and feedback reduce them.

Autocratic, democratic, laissez-faire, transformational and servant leadership. Effective leaders adapt the style to the situation and team.

Kotter describes eight steps beginning with creating urgency. Lewin describes three phases: unfreeze, change and refreeze.

Goals that are Specific, Measurable, Achievable, Relevant and Time-bound.

Planning, organizing, staffing, directing and controlling.

Competing, collaborating, compromising, avoiding and accommodating. Collaborating usually works best for important issues.

For-profit, not-for-profit and government-owned, and independent or chain-affiliated. Ownership influences resources, governance and decision-making.

Financial, customer, internal processes, and learning and growth. It balances results across areas rather than only financial measures.

Assess the environment, set mission and goals, form strategies, build action plans with owners and timelines, measure results and review the plan regularly.

Forming, storming, norming, performing and adjourning.

Honesty, resident welfare and rights, confidentiality, competence, avoiding conflicts of interest and compliance with the law. Professional bodies such as ACHCA publish codes.

A multidisciplinary group that reviews ethical dilemmas and policy and advises staff and families. It recommends rather than decides.

It is legally responsible for the facility, sets policies for management and operation, appoints the licensed administrator and ensures that the facility is run effectively.

The chain of command is the line of authority and reporting. The span of control is the number of people a manager directly supervises.

The idea that residents have a right to make choices that carry some risk. Use negotiated risk plans that balance safety with autonomy.

The ability to understand and manage one's own emotions and recognize and respond to others', including self-awareness, self-regulation, motivation, empathy and social skill.

Hygiene factors such as pay and conditions prevent dissatisfaction. Motivators such as achievement and recognition drive satisfaction.

Shared values, beliefs and behaviors in the workplace. Leaders shape it through what they model, reward and tolerate.

Identifying and developing future leaders so key roles can be filled smoothly and operations continue when people leave.

The mission states why the organization exists. The vision describes what it hopes to become. The values are the principles that guide behavior.

Assigning tasks and the authority to do them to another person. Accountability remains with the person who delegated.

To review resident status, staffing, new admissions, incidents and risks, coordinate across departments and act quickly on problems.

To lead and manage the whole facility, ensuring quality care, regulatory compliance, sound finances, staffing and a safe environment, and to answer to the governing body.

Act quickly on safety, communicate clearly and honestly, follow the emergency plan, support staff, document decisions and review lessons afterward.

Identify the issue, gather facts, consider stakeholders and values, list options, decide, act and evaluate the outcome.

Groups such as AHCA/NCAL, LeadingAge and state associations provide advocacy, education and updates on regulations.

Staff and residents can report concerns confidentially or anonymously without retaliation, which helps detect and fix problems early.

Residents and staff come from diverse backgrounds. Culturally responsive care, communication and policies improve outcomes, trust and satisfaction.

Federal rules are enforced through surveys, but many states give residents a private right of action under their own resident rights statutes.

Adult Protective Services investigates abuse of vulnerable adults mainly in community settings. The long-term care ombudsman advocates for residents in facilities. Facility abuse is also reported to the state survey agency.

Civil cases seek money or remedies and use a preponderance of the evidence. Criminal cases seek punishment and require proof beyond a reasonable doubt. Abuse or neglect can bring both.

Meet the state's education requirements, complete an administrator-in-training program, pass the NAB exams and any state exam, and keep up with continuing education.

Work with legal counsel, review relevant records without changing them, answer truthfully and only what is asked, and never alter or destroy documents.

Assault is a threat of harmful contact. Battery is unconsented touching. False imprisonment is unlawful confinement, which can include improper restraint.

Damages awarded to punish reckless or egregious conduct, beyond compensation for losses. Some insurance policies do not cover them.

Duty of care, breach of that duty, causation and damages. All four must be proven.

A wrongful death claim is brought by family for their loss after a death. A survival action lets the estate pursue the claims the resident could have brought.

That competent persons have a constitutional right to refuse treatment and that a state may require clear and convincing evidence of an incapacitated person's wishes.

That unjustified segregation of people with disabilities is discrimination under the ADA. People should receive services in the most integrated setting appropriate to their needs.

A nursing facility must be administered by a licensed nursing home administrator, who is responsible for the overall management of the facility.

"The thing speaks for itself." Negligence is inferred when an injury would not ordinarily occur without it and the defendant controlled the cause.

A directive to preserve all records and data related to a claim or lawsuit. Destroying them can bring sanctions for spoliation.

A process to identify, analyze, control and finance risks through policies, incident review, training, insurance and follow-up.

The time limit for filing a lawsuit. It varies by state and claim type and may be extended, for example when the resident is incapacitated.

False statements that harm someone's reputation. Libel is written and slander is spoken.

The facility is liable when it hires or keeps unfit staff or fails to supervise them, and a resident is harmed as a result.

Employers are legally responsible for the negligent acts of employees committed within the scope of their employment.

A guardian is appointed by a court for a person found incapacitated. An agent is chosen by the person through a power of attorney, and a durable power of attorney remains valid after incapacity.

A health care proxy lets an agent make medical decisions. A financial power of attorney covers money and property. Ask for copies of each and check their scope.

Occurrence policies cover events during the policy period regardless of when claimed. Claims-made policies cover claims filed during the policy, so tail coverage is needed after a change.

To record facts of an event for quality improvement and risk management. Keep it objective and do not refer to it in the medical record.

What a reasonably prudent provider would do in the same situation. Expert witnesses often testify about it.

General liability, professional liability, property, workers' compensation, directors and officers, cyber and umbrella or excess coverage.

Develop specialty programs, such as short-stay rehabilitation, wound care, dementia care or ventilator care, supported by trained staff and good outcomes.

Hospitals and accountable care organizations choose preferred post-acute partners based on star ratings, readmission rates and communication, so quality and responsiveness build referrals.

Plans decide which facilities are in network. Building contracts, meeting plan quality and communication expectations and managing authorizations help secure admissions.

Prompt updates, care conferences and a responsive point of contact build trust, reduce complaints and improve satisfaction and referrals.

Use a designated spokesperson, give factual statements, coordinate with the corporate office and counsel, and never release protected health information.

Respond promptly and professionally, thank the reviewer, offer to discuss offline and never reveal protected health information.

Local demographics, competitor strengths and weaknesses, referral patterns and a SWOT review to guide services and marketing.

Builds referral relationships, screens inquiries, coordinates assessments and admissions with clinical staff, tracks census and reports to the administrator.

Open houses, speaking and education events, volunteer programs, partnerships with schools and faith groups and visibility in the local community.

Be truthful, do not guarantee outcomes, and avoid anything of value to induce referrals, which could violate the Anti-Kickback Statute. Respect resident choice.

A CMS public website with nursing home ratings. Consumers and referrers use it, so marketing must accurately reflect the facility's ratings and quality.

Census is the number of residents in the facility. It drives revenue while many costs stay fixed, so administrators track it daily against budget.

Marketing spending divided by the number of admissions it produced. It helps judge return on investment by channel.

To build census and a strong reputation through relationships with referral sources, residents and families, while staying truthful and resident-centered.

Clean, odor-free spaces, friendly staff, an honest description of care, time for questions and clear next steps for admission.

Track inquiries and admissions daily, manage payer mix, shorten the time to fill vacant beds, support readmissions and keep discharges safe and planned.

Standardized surveys such as the Nursing Home CAHPS, plus care conferences, comment cards and resident and family councils, with results tracked and acted on.

Hospital discharge planners, physicians, home health agencies, assisted living communities, managed care plans, accountable care organizations and families.

Families and discharge planners often decide within hours. Quick answers, clear information and follow-up improve conversions.

It shows which referral sources and steps work. A simple tracking system follows each lead from inquiry to tour to admission.

Isolation must be no more than needed. Explain the reasons, protect dignity, provide social contact and activities, and keep the resident's other rights.

RNs assess, plan and supervise care. LPNs/LVNs give care under RN or physician direction. CNAs give basic care and observe. State nurse practice acts define each scope.

Under double lock in a separate, permanently fixed compartment, with accurate records of receipt and disposition and counts reconciled at shift change.

A licensed nurse receives the order, reads it back to confirm it, and records it. The prescriber must authenticate it within the time frame set by state law and facility policy.

Put on the gown, then mask or respirator, then eye protection, then gloves. Remove gloves first, then eye protection, then the gown, then the mask, and finish with hand hygiene.

Gown and glove use during high-contact care for residents with wounds, indwelling devices or multidrug-resistant organisms. They help prevent spread without full isolation.

Identify and report to the health department, isolate or cohort residents, apply transmission-based precautions, limit movement, communicate with families and review the response afterward.

Basic infection control for all residents: hand hygiene, gloves, gowns, masks and eye protection based on risk, safe injection practice, respiratory etiquette, and cleaning of equipment.

At least 75 hours of approved training including supervised practice, then a competency evaluation. Aides need 12 hours of in-service each year and a performance review at least every 12 months.

McGeer criteria are surveillance definitions of infection for long-term care. Loeb minimum criteria help decide when to start antibiotics for suspected infection.

Urinary tract infections, respiratory infections including influenza, pneumonia and COVID-19, skin and soft tissue infections, and gastrointestinal infections such as C. difficile and norovirus.

Locked storage, access limited to authorized staff, proper temperature, refrigerated items in a locked refrigerator at about 36 to 46 degrees F, and removal of expired or discontinued drugs.

Extra measures for known or suspected infections: contact, droplet and airborne precautions, each with specific room and protective equipment rules.

Reviews each resident's drug regimen at least monthly and reports irregularities to the attending physician, medical director and director of nursing. The facility must act on the report.

A written program with surveillance, prevention, outbreak control and reporting, led by a designated infection preventionist who has specialized training and is at the facility at least part-time.

An exposure control plan, training, protective equipment, safe sharps, hepatitis B vaccination offered at no cost to at-risk employees, and post-exposure follow-up.

CMS repealed it by interim final rule in December 2025, effective February 2, 2026. The 3.48 hours per resident day and 24/7 RN requirements are gone. RN 8 hours a day, a full-time RN DON and the facility assessment remain. Verify current status.

Educate residents and offer influenza and pneumococcal vaccines, and provide COVID-19 vaccine education and offers. Residents may refuse, and the facility documents education, offers and refusals.

A step-wise attempt to lower or stop a psychotropic drug. It is attempted in two separate quarters during the first year, at least a month apart, and then annually unless clinically contraindicated.

A required program with protocols and monitoring to make sure antibiotics are prescribed only when needed and for the right drug, dose and duration.

Comparing a resident's current medication orders with prior lists to find omissions, duplications and conflicts. It is done on admission, readmission and transfers between care settings.

A written review of the resident population, services and resources used to decide staffing and competencies. It must be reviewed and updated at least annually and when major changes occur.

A full-time registered nurse who manages nursing services. The DON cannot also serve as charge nurse, except in small facilities under limited waivers.

A state list of certified nurse aides, including findings of abuse, neglect or misappropriation. Facilities check it before hiring and cannot use a person with such a finding.

One used in an excessive dose, for too long, without adequate monitoring, without an adequate indication, or with adverse effects that should lead to a change.

A medication error rate of 5% or more is a deficiency, and no significant medication errors are permitted.

A documented diagnosis or specific condition the drug treats, a clear indication, monitoring, and a care plan. Use must be necessary and the resident or representative should be informed.

Sufficient nursing staff for resident needs, a licensed nurse in charge on each shift, and a registered nurse on duty at least 8 consecutive hours a day, 7 days a week.

Wash the area with soap and water, report immediately, get a medical evaluation and post-exposure follow-up, and record the incident on the sharps injury log as OSHA requires.

Daily nurse staffing data, including facility name, date, census and hours worked by licensed and unlicensed nursing staff. It must be easy to see and kept for 18 months.

Screen residents on admission and staff on hire using a skin test or blood test, then follow CDC guidance and state rules for repeat testing and exposure.

When hands are visibly soiled and with C. difficile or norovirus exposure. Alcohol-based rub is otherwise preferred.

When the interdisciplinary team decides it is clinically appropriate and safe. The medications must be stored securely and the plan documented in the care plan.

Its spores survive alcohol-based products. Use soap and water for hands and a sporicidal, bleach-based disinfectant for surfaces.

To reduce the risk of Legionella and other waterborne pathogens. CMS expects a plan with risk assessment, controls and monitoring.

A visual inspection monthly, an annual maintenance check by a qualified person and the correct class for the hazard, such as ABC for most areas.

With a system that records each resident's location, such as ID bands or tags with medical information, and a count at the receiving site.

Weigh the hazard, resident risk, building safety, time available and resources. Follow the plan and instructions from emergency management officials.

Tested monthly for at least 30 minutes under load, with power transferring within 10 seconds and results documented.

Regular inspection and testing of pull stations, detectors, notification devices and monitoring, with written records kept for surveyors.

At least quarterly on each shift, at unexpected times and under varied conditions, with documentation of each drill.

Approved locks on exit doors, often used on secured units, that release within 15 seconds of force or sooner with the alarm, and release with fire alarm or sprinkler activation.

Extra precautions used when life safety features are deficient or during construction, such as added drills, fire watch and exit inspections, to keep residents safe.

CMS requires all long-term care facilities to have complete, supervised automatic sprinkler systems, which are inspected, tested and maintained on schedule.

Lighting in exits and corridors that comes on automatically in a power loss and lasts at least 90 minutes, with regular testing.

No more than four residents per room, at least 80 square feet per resident in multiple rooms and 100 square feet in single rooms, with a bed, chair, closet and window. Newer construction is limited to two residents.

Risk assessment and planning, policies and procedures, a communication plan, and training and testing. The plan is reviewed and updated at least annually.

Use ground-fault circuit interrupters where required, avoid overloaded outlets and extension cords, inspect resident-owned appliances, and prohibit unsafe items such as space heaters.

A pest control program, usually under contract, that keeps the facility free of pests. Keep service records and respond quickly to sightings.

Horizontal moves residents to a safe area on the same floor, vertical moves them between floors, and total moves everyone out of the building.

Hot water at resident-use fixtures must be kept within a safe range, generally about 105 to 120 degrees F, to prevent scalding while limiting Legionella risk. Follow CMS and state rules.

Because many residents cannot evacuate quickly, staff move them to an adjacent smoke compartment and rely on compartmentation rather than a full evacuation.

Pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep side to side.

Rescue residents in danger, sound the Alarm, Contain the fire by closing doors, and Extinguish or Evacuate.

Two exercises: a full-scale exercise (community-based or facility-based) and one additional exercise, which may be a tabletop. Document and review the results.

Food, water, medical and pharmaceutical supplies, alternate power for temperature control and lighting, fire detection and sewage and waste disposal.

A hood and automatic fire suppression system over cooking equipment that is inspected twice a year, regular duct cleaning, and a Class K extinguisher for cooking oils.

A comfortable and safe temperature, with CMS rules requiring 71 to 81 degrees F in areas used by residents.

An all-hazards assessment of the risks the facility faces, such as storms, fires, outbreaks and power loss, ranked by likelihood and impact to guide planning.

A scheduled program of inspecting, servicing and repairing equipment and systems, with work orders and logs, to prevent failures and show compliance.

A section of the building divided by smoke barriers so smoke and fire are contained. Compartments are generally limited to 22,500 square feet with a maximum travel distance of 200 feet.

A review before construction or renovation of risks to residents, such as dust and mold, with barriers, ventilation controls, cleaning and monitoring.

Decorations must be flame-retardant and limited so they do not spread fire. Open flames such as candles are not allowed, and corridors and exits must stay clear.

Residents must be able to call for staff from their bed and from toilet and bathing facilities. Staff must respond promptly and the system must be tested.

Designated smoking areas, supervision and assessment of residents' ability to smoke safely, no smoking near oxygen, and safe disposal of materials.

Contact information for staff, residents' families and physicians, and state and local officials, plus alternate communication methods if phones fail.

Keep cylinders upright and secured with caps on, separate full and empty ones, post signs, and keep them away from heat and ignition sources. Larger quantities need rated storage rooms.

When the fire alarm or sprinkler system is out of service for more than four hours in a 24-hour period. Notify authorities and monitor the building until it is restored.

The 2012 edition of NFPA 101 and the 2012 edition of NFPA 99 for health care facilities, as adopted by CMS.

They secure receiving facilities and transport in advance and link the facility with local emergency management for shared resources and information.

The facility sends written requirements to several vendors, scores their proposals on cost, quality and references, and negotiates with the best option.

By comparing cost with expected benefits using payback period, return on investment and lease-versus-buy analysis, and considering maintenance and life span.

Check exclusion lists, insurance certificates and licenses, require business associate agreements where PHI is shared, and review performance regularly.

Offer, acceptance, consideration, legal capacity of the parties and a lawful purpose, with mutual agreement.

A group that negotiates discounted prices for many members. Payment structures must fit the Anti-Kickback safe harbor.

Matching the purchase order, the receiving report and the vendor invoice before payment to prevent errors and fraud.

A promise by one party to cover the other's losses from specified claims. Review who indemnifies whom and whether insurance backs it.

Setting minimum and maximum quantities for each supply, reordering at set points, using first in first out and counting regularly to avoid shortages and waste.

Scope of services, price, term and renewal, termination rights, indemnification, insurance, confidentiality, compliance and HIPAA terms, and performance standards.

Written duties and time commitment, compensation at fair market value not tied to referrals, and compliance with the Anti-Kickback Statute.

Timely delivery and emergency supply, unit-dose packaging, consultant pharmacist services, records, quality and compliance with federal and state law.

A valid CLIA certificate for lab work, timely results, reporting of critical values, and billing that follows payer rules.

The facility. It must make sure contracted services, such as therapy or staffing, meet professional standards and the care plan.

It protects the facility and residents if the vendor's staff cause harm. Request certificates of insurance and confirm the facility is named where appropriate.

To avoid unwanted renewals, renegotiate rates, confirm vendor insurance and compliance, and prevent lapses in needed services.

Surveyors may not require disclosure of QAA committee records except to the extent needed to verify that the committee exists and meets requirements.

Short-stay residents have stayed 100 cumulative days or fewer. Long-stay residents have stayed more than 100 cumulative days.

It is based on recent standard and complaint survey results and is relative within each state. The top 10% of facilities earn 5 stars, the middle 70% earn 2 to 4 stars and the bottom 20% earn 1 star.

It starts with the health inspection rating and is adjusted up or down according to the staffing and quality measure ratings.

Falls with major injury, high-risk pressure ulcers, antipsychotic use, urinary catheter use, urinary tract infections, weight loss and worsening ability to move independently.

Rehospitalization after admission, emergency department visits, improvement in function and newly received antipsychotic medication.

Measures calculated mainly from MDS data that show how well a facility cares for residents, such as falls, pressure injuries and antipsychotic use. CMS reports them on Care Compare.

Health inspections, staffing and quality measures, each rated, and combined into an overall rating from 1 to 5 stars. Health inspection ratings are relative within each state.

MDS quality measures, incident and fall reports, infection surveillance, complaints and grievances, satisfaction surveys, staffing and turnover data and survey results.

An environment where staff can report errors and near misses without fear of unfair blame, while still being held accountable for reckless behavior.

A focused, data-driven project that targets a high-risk, high-volume or problem-prone area, sets goals, tests changes and tracks results.

A graph of data over time that shows trends and whether a change led to improvement.

Comparing the facility's results with state and national averages or top performers, such as on Care Compare, to set realistic goals.

A proactive method that maps a process, identifies how it might fail, ranks the risks and plans safeguards before harm occurs.

Quality Assurance and Performance Improvement. The elements are design and scope, governance and leadership, feedback data systems and monitoring, performance improvement projects, and systematic analysis and systemic action.

A structured method, such as the five whys or a fishbone diagram, that finds the underlying causes of a problem rather than only fixing symptoms.

Plan, Do, Study, Act. A repeating method for testing a change on a small scale, measuring results and adjusting before wider use.

A written plan describing how the facility will carry out the QAPI program, available to surveyors and updated regularly, with data, priorities and responsibilities.

Early detection of change in condition, structured communication tools such as SBAR, medication management, advance care planning, strong physician coverage and good transitions of care.

The director of nursing, medical director or designee, at least three other staff including the administrator or other leader, and the infection preventionist. It meets at least quarterly.

Yes. The resident may choose an attending physician who meets facility and regulatory requirements, and must be told if the physician is no longer able to serve.

Necessary for the resident's welfare, the resident's health improved, safety of others endangered, health of others endangered, nonpayment after notice, or the facility ceases to operate.

The willful infliction of injury, unreasonable confinement, intimidation or punishment that results in physical harm, pain or mental anguish.

Failure of the facility or its staff to provide the goods and services needed to avoid physical harm, pain, mental anguish or emotional distress.

Check state nurse aide registries and licensing boards and run background checks. Do not employ anyone found guilty of abuse, neglect or misappropriation.

To send and receive mail promptly and unopened, to access a telephone and, where available, the internet and other communication, and to receive materials in a form they can use.

The resident has capacity, receives information on the condition, benefits, risks and alternatives, and agrees voluntarily.

Autonomy, beneficence, nonmaleficence and justice.

PRN psychotropic orders are limited to 14 days. A PRN antipsychotic cannot be renewed unless the prescriber evaluates the resident and documents the rationale.

Dignity and respect, self-determination, privacy and confidentiality, communication, visitation, participation in care planning, refusal of treatment, freedom from abuse, neglect and restraints, management of finances, grievances and protection in transfer and discharge.

Report immediately, and no later than 2 hours if abuse or serious bodily injury is suspected, or 24 hours if there is no serious bodily injury. Reports go to the administrator and the state survey agency.

Residents may voice grievances without fear of reprisal. The facility must post how to file, designate a grievance official, resolve concerns promptly and give a written decision.

The facility must safeguard and account for funds that residents choose to deposit. Balances over $100 go in an interest-bearing account, quarterly statements are provided, and a surety bond is required.

Residents may receive visitors of their choosing at any time, with their consent, and the facility may not restrict visits without a clinical or safety reason. Ombudsmen and government officials have access too.

Residents have the right to be free from physical or chemical restraints used for discipline or convenience, or not required to treat medical symptoms.

An advocate for residents under the Older Americans Act who investigates complaints, has access to facilities and residents, and must be given notice of involuntary transfers and discharges.

Providers that receive Medicare or Medicaid funds must give adult patients written information about their right to make care decisions and to prepare advance directives.

Use the resident's preferred name, knock before entering, offer choices, keep personal care private and avoid labels such as feeders.

Privacy during personal care and treatment, in telephone calls, mail and visits, and confidentiality of personal and medical records, subject to HIPAA and state law.

The facility must give written information on the state bed-hold policy and its own readmission policy before and at the time of transfer, such as to a hospital.

Physician Orders for Life-Sustaining Treatment are medical orders for seriously ill or frail patients that travel with them across settings. An advance directive states wishes but is not itself a medical order. The name varies by state.

Written instructions about future health care, such as a living will or a health care power of attorney. Facilities must inform residents of their right to have one and cannot condition care on having one.

A movement to make nursing homes more homelike and resident-directed, through models such as the Eden Alternative and the Green House Project.

The deliberate misplacement, exploitation or wrongful use, temporary or permanent, of a resident's belongings or money without consent.

Care built around each resident's preferences, values and goals, with the resident as an active partner in decisions.

Capacity is a clinical judgment about a person's ability to understand and decide. Competency is a legal determination made by a court.

The right to make choices about daily life and health care, such as schedules, activities, and care plan decisions. The facility must honour preferences whenever feasible.

The Centers for Medicare & Medicaid Services administers Medicare and Medicaid, sets the requirements of participation, and oversees enforcement. State survey agencies conduct inspections under contract.

Protect residents from further harm, investigate thoroughly, and report results of the investigation to the administrator and state agency within 5 working days.

Allow residents to organize and meet, provide private space, assign a staff liaison, and respond in writing to council concerns and recommendations.

Written notice at least 30 days in advance, in a language and manner the resident understands, with a copy to the ombudsman. Shorter notice is allowed in specific emergencies.

The right to refuse treatment, refuse to take part in experimental research, and make an advance directive. The facility must explain the likely consequences and document the refusal.

42 CFR Part 483, Subpart B. CMS sets the requirements, and state survey agencies inspect facilities for compliance.

The Omnibus Budget Reconciliation Act of 1987 (OBRA 87), also called the Nursing Home Reform Act. It set federal standards for quality of care and residents' rights.

A health care agent named in a power of attorney, a court-appointed guardian, or a surrogate chosen by state law. Involve the resident as much as possible.

By risk. Complaints alleging immediate jeopardy must be investigated within 2 working days, with other complaints investigated within set time frames according to priority.

Severity has four levels from no harm with minimal potential to immediate jeopardy, and scope is isolated, pattern or widespread. Together they give letter grades A through L.

At least every 15 months, with a statewide average of 12 months or less.

Numbers assigned to federal nursing home requirements, found in Appendix PP of the State Operations Manual, used to cite deficiencies. For example, F689 covers accident hazards.

Offsite preparation, entrance conference, initial tour, resident sample selection, observations, interviews and record review, team deliberation and an exit conference.

Standard surveys, complaint and facility-reported incident investigations, revisit surveys, life safety code surveys and focused infection control surveys.

A resident roster, census and resident-specific lists such as those with pressure injuries or restraints, staffing and shift information, and key policies.

Civil money penalties, denial of payment for new admissions, directed plans of correction, directed in-service training, state monitoring, temporary management and termination.

A fine imposed per day or per instance for noncompliance. The amount depends on severity, scope, history and the facility's financial condition.

A follow-up survey to verify that deficiencies have been corrected. The date of compliance is set when correction is verified.

Noncompliance that has caused or is likely to cause serious injury, harm, impairment or death. It is the highest severity (J, K or L) and must be corrected immediately.

A process to challenge cited deficiencies, requested within the 10 days after receiving the statement. It does not delay enforcement actions.

A finding of serious deficiencies in areas such as resident rights, quality of life or care, or nursing services at a level above isolated minor harm. It triggers notice and enforcement actions.

The Statement of Deficiencies and Plan of Correction. It lists cited deficiencies and the facility's response, and is available to the public.

A CMS program for facilities with a history of serious quality problems. They are surveyed more often and must show sustained improvement or face termination.

How the problem was fixed for affected residents, how others at risk are identified, systemic changes, how it will be monitored and a completion date. It is due within 10 calendar days.

Be cooperative and professional, appoint a liaison, provide documents promptly, keep a log of requests, clarify findings and never alter or fabricate records.

The most recent survey results in a place readable by residents and visitors, along with notice of how to obtain related reports and plans of correction.

Mandatory denial of payment for new admissions applies if substantial compliance is not achieved within 3 months. Termination from Medicare and Medicaid follows if not achieved within 6 months.

State survey agencies, under agreement with CMS, inspect facilities for compliance with federal requirements for Medicare and Medicaid participation.