Basic self-care tasks: bathing, dressing, eating, toileting, transferring, and walking. Nursing homes assess and track each resident’s ability to perform ADLs independently, with assistance, or not at all. The MDS documents ADL scores at every assessment period.

State agency responsible for investigating reports of abuse, neglect, and exploitation of vulnerable adults including nursing home residents. In Arkansas, APS falls under the Department of Human Services. Complaints can be filed through the Adult Maltreatment Hotline at 1-800-482-8049.

Legal document stating a person’s wishes about medical treatment if they become unable to speak for themselves. Includes living wills and healthcare power of attorney designations. Facilities are required to ask about advance directives at admission and must honor them.

Medications originally developed for schizophrenia and psychosis, frequently prescribed off-label in nursing homes to manage behavioral symptoms of dementia. CMS tracks antipsychotic use as a quality measure because overuse is widespread and constitutes chemical restraint when used without a proper diagnosis.

When food, liquid, or saliva enters the airway instead of the esophagus. Residents with dysphagia are at high risk. Aspiration pneumonia is one of the leading causes of death in nursing home residents and is often preventable with proper positioning and modified diet protocols.

Electronic record of every action taken in a digital health record: who accessed it, when, what was changed, and from what device. Audit trails expose ghost charting, retroactive documentation, and falsified entries that would not be visible in a standard chart review.

A structured cognitive assessment administered to nursing home residents as part of the MDS. Scores range from 0 to 15. A score below 8 indicates severe cognitive impairment. Scores are used to determine what level of oversight and protection a resident requires.

A standardized risk assessment tool for pressure injuries. Scores six factors including sensory perception, moisture, activity, mobility, nutrition, and friction on a scale where lower total scores indicate higher risk. Federal regulations require regular Braden assessments and intervention when risk is identified.

Section of the RAI process requiring facilities to investigate specific clinical problems identified in the MDS, determine their causes, and address them in the care plan. CAAs cover falls, dehydration, pressure ulcers, behavioral symptoms, and other high-risk conditions.

Written plan developed within 7 days of a resident’s comprehensive MDS assessment that details individualized goals, interventions, and the team member responsible for each area of care. Residents and families have the right to participate in care planning meetings and to receive a copy of the plan.

Any drug used to manage behavior, restrict freedom of movement, or sedate a resident in a way that is not required to treat a diagnosed medical condition. Chemical restraints require specific clinical justification. Antipsychotics used solely for staff convenience are chemical restraints under federal regulation.

Financial fines imposed by CMS on nursing facilities found to have violated federal regulations. Penalties range from hundreds to thousands of dollars per day of noncompliance depending on scope and severity. CMP data is publicly available through the CMS Care Compare website.

When nursing notes, assessments, or care plans are copied and pasted from one date to another with little or no individualized content. Common in electronic health record systems. Cloned documentation means staff documented care without actually assessing or delivering it.

Medical care focused on managing symptoms and quality of life rather than curing illness. Unlike hospice, comfort care does not require a terminal prognosis or an agreement to stop curative treatment. Facilities sometimes use the term loosely and inconsistently.

Federal requirements nursing homes must meet to receive Medicare and Medicaid reimbursement, established under the Nursing Home Reform Act of 1987. Violations of CoPs result in deficiency citations during surveys. Facilities that repeatedly fail to meet CoPs risk losing federal funding entirely.

Permanent shortening of a muscle, tendon, or joint caused by immobility, disuse, or inadequate repositioning. Contractures are largely preventable with proper range-of-motion exercises and consistent repositioning. They develop over weeks and months of inadequate care.

Non-medical personal care services including bathing, dressing, feeding, and assistance with daily activities. Custodial care is not covered by Medicare but is covered by Medicaid for eligible residents. It is the most common type of care provided in long-term care settings.

A type of pressure injury where damage to underlying muscle and tissue occurs before visible skin breakdown. Appears as a purple or maroon localized area on intact skin. DTIs indicate sustained pressure over time and require investigation of repositioning practices before they became visible.

A written finding issued by state surveyors when a nursing facility fails to meet federal or state regulations. Each citation is assigned an F-Tag number and a scope and severity rating. Deficiency history is public record on the CMS Care Compare website and in state inspection reports.

Medical order directing staff not to perform CPR if a resident’s heart or breathing stops. A DNR applies only to resuscitation, not to other treatments such as IV fluids, medications, or hospitalization. A DNR does not mean “do not treat.”

Legal document authorizing a designated person to make financial decisions on behalf of someone who becomes incapacitated. A DPOA does not automatically grant authority over medical decisions, which requires a separate Healthcare Power of Attorney. Nursing home residents are frequently targeted for financial exploitation through misuse of DPOA.

Difficulty swallowing. Affects a significant portion of nursing home residents, particularly those with dementia, stroke, or Parkinson’s disease. Requires a formal swallowing evaluation and modified diet or thickened liquids as clinically indicated. Unmanaged dysphagia is a direct risk factor for aspiration pneumonia.

When a resident with cognitive impairment leaves a secured unit or facility without staff awareness. Elopement is a serious safety event that must be reported and investigated. It signals a failure of supervision, inadequate staffing levels, or faulty security equipment.

Numeric code assigned to each federal regulation governing nursing homes. For example, F689 covers accident and injury prevention, F600 covers abuse prohibition, and F684 covers quality of care. F-Tags allow you to look up the specific regulation a facility was cited for and understand the legal standard it failed to meet.

A fall resulting in physical harm requiring medical treatment. Nursing facilities must report, investigate, and document all falls. A pattern of falls with injury in the same resident indicates failure to implement or update the fall prevention care plan after each event.

Documenting care that was never provided, often created in advance or after the fact to fill gaps in the medical record. One of the most common forms of documentation fraud in nursing home neglect cases. Detectable through audit trails, staffing records, and comparison with witness accounts.

A formal complaint filed by a resident or their representative about care, treatment, or conditions in a facility. Federal law requires facilities to have a grievance process, respond in writing, and not retaliate against residents who file grievances. Every grievance and the facility’s written response should be kept on file.

A court-ordered legal relationship giving one person authority to make personal and sometimes financial decisions for another who has been found legally incapacitated. Unlike a power of attorney, guardianship requires judicial approval. Nursing facilities must follow the directions of a court-appointed guardian.

Legal document designating a person to make medical decisions on behalf of someone who cannot make them independently. The HCPOA agent has authority only when the principal lacks decision-making capacity. Nursing homes are required to recognize and document the HCPOA in the resident’s chart.

A Medicare and Medicaid benefit providing end-of-life care focused on comfort rather than cure for individuals with a terminal prognosis of six months or less if the illness runs its natural course. Enrolling in hospice requires the resident to agree to forgo curative treatment for the terminal diagnosis. Hospice services are provided by an outside agency, even when the resident remains in the nursing home.

The most serious deficiency level assigned by CMS surveyors. Defined as a situation in which the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy findings require the facility to correct the problem before surveyors leave the building.

Internal facility document created after an unexpected event such as a fall, injury, medication error, or altercation. Incident reports document what happened, who was involved, what immediate action was taken, and what follow-up is planned. They are separate from the medical record but can be requested by authorized representatives in many states.

The group of professionals responsible for developing and updating a resident’s care plan. Typically includes the attending physician or nurse practitioner, nursing staff, social worker, dietitian, therapist, and activities staff. Families have the right to participate in IDT meetings and to receive written meeting notes.

A medical record entry made after the fact, hours or days after the documented event. Late entries are not automatically fraudulent but must be clearly labeled with the actual date and time they were written and the date of the event they describe. Unlabeled late entries that appear to be contemporaneous are a documentation red flag.

An advocate for nursing home and assisted living residents, authorized by the Older Americans Act. Ombudsmen investigate complaints, conduct regular facility visits, and work to resolve problems on behalf of residents. In Arkansas, the program is administered through Area Agencies on Aging. The ombudsman is free and confidential.

The official record of every medication given to a resident, including the drug, dose, route, time, and the initials of the staff member who administered it. Gaps in the MAR, missing signatures, or PRN medications documented without assessment notes are significant documentation red flags.

A standardized federal assessment tool completed for every Medicare and Medicaid nursing home resident at admission and at regular intervals. The MDS captures functional status, cognitive status, behavioral symptoms, diagnoses, and clinical conditions. MDS data drives care planning, reimbursement, and the CMS star rating system.

Joint federal and state program providing health coverage for low-income individuals, including nursing home care for those who meet both clinical and financial eligibility requirements. Medicaid pays for the majority of long-term nursing home care in the United States. Eligibility rules, covered services, and reimbursement rates vary by state.

The process by which a person uses their countable assets to pay for care before becoming financially eligible for Medicaid. Federal rules govern which assets are countable, which are exempt, and how assets held by a community spouse are treated. Facility staff are not Medicaid eligibility experts and may give families incorrect information.

Hospital insurance that covers skilled nursing facility care for up to 100 days per benefit period following a qualifying inpatient hospital stay of at least three days. Days 1 through 20 are fully covered. Days 21 through 100 require a daily copay. Coverage ends when the resident no longer requires skilled care or when the 100-day limit is reached.

Medical insurance covering physician services, outpatient therapy, and some preventive services in nursing home settings. Part B coverage continues even when Part A skilled care benefits are exhausted. Does not cover custodial or personal care.

Medical Orders for Life-Sustaining Treatment (MOLST) or Physician Orders for Life-Sustaining Treatment (POLST) is a portable medical order signed by a physician that travels with the resident across care settings. More detailed than a DNR, it specifies preferences for CPR, mechanical ventilation, hospitalization, and artificial nutrition.

Under federal regulation, neglect is the failure of a facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect includes acts of omission, not just active harm. Intent is not required to establish neglect.

Medical order prohibiting a resident from eating or drinking anything, typically before a procedure or during an acute medical event. Extended NPO status without an alternative nutrition plan is dangerous, particularly for frail elderly residents who are already at risk of malnutrition and dehydration.

Chronological written record of observations, assessments, interventions, and resident responses documented by nursing staff. In a neglect case, nursing notes are the primary evidence of what care was or was not provided. Missing notes, template language, and notes that do not match other records are key red flags.

Arkansas state agency within the Department of Human Services that licenses, certifies, and surveys nursing facilities in Arkansas. The OLTC investigates complaints about nursing home care and maintains inspection records. Complaints can be filed by calling the Arkansas Adult Maltreatment Hotline at 1-800-482-8049.

Specialized medical care focused on relief from the symptoms and stress of serious illness, provided alongside curative or life-prolonging treatment. Unlike hospice, palliative care does not require a terminal prognosis or agreement to stop aggressive treatment. It is appropriate at any stage of a serious illness.

A standardized tool used to screen for depression. Scores range from 0 to 27. Scores of 10 or above indicate moderate to severe depression requiring clinical attention. PHQ-9 results are captured in the MDS. Untreated depression in nursing home residents is associated with functional decline, refusal to eat, and increased mortality.

Any device, material, or equipment attached to or near a resident’s body that restricts freedom of movement and cannot be easily removed by the resident. Federal law requires facilities to minimize restraint use. Any restraint requires informed consent, a physician order, and regular reassessment of continued need.

Written document submitted by a nursing facility in response to deficiency citations, describing what the facility will do to correct each deficiency, how it will prevent recurrence, and by what date. Plans of Correction are public record. Reviewing them tells you whether a facility’s proposed corrections are substantive or superficial.

Latin for “as needed.” A PRN medication or treatment order gives nursing staff discretion to administer based on clinical assessment of the resident’s condition. PRN orders require parameters specifying when to administer and an assessment note documenting the clinical reason each time they are given.

Localized damage to the skin and underlying tissue caused by sustained pressure, friction, or shear, usually over a bony area. Staged from Stage 1 (non-blanchable redness on intact skin) to Stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle). A new or worsening pressure injury in a long-term resident is a potential indicator of neglect.

Standardized metrics calculated from MDS data used to evaluate nursing home performance across facilities. Quality measures include rates of pressure injuries, falls, antipsychotic use, weight loss, hospitalizations, and depression. QM data appears on the CMS Care Compare website and factors into the five-star quality rating.

The federally mandated process used to assess and plan care for every nursing home resident receiving Medicare or Medicaid. The RAI includes the MDS, Care Area Assessments, and the care planning process. Required at admission, quarterly, annually, and after any significant change in condition.

Federal rights guaranteed to all nursing home residents under the Nursing Home Reform Act of 1987. These include the right to be treated with dignity, refuse treatment, participate in care planning, file grievances without retaliation, and have visitors. Facilities must provide residents with a written notice of their rights upon admission.

The individual designated in a resident’s admission paperwork as the person authorized to make decisions and receive communications from the facility. The responsible party designation does not carry the same legal weight as a Healthcare Power of Attorney or guardianship. It is a facility contact designation, not a legal authority.

Medical record entries created after the fact to fill gaps in the chart, particularly following an adverse event, complaint, or legal notice. Distinguishable from legitimate late entries because the actual creation date in the audit trail does not match what the note appears to document.

A standardized communication framework used by nursing staff to report changes in a resident’s condition to physicians and other providers. Each component structures the communication: what is happening now, what the context is, what the nurse believes is occurring, and what action is requested.

A grid used by CMS to rate each deficiency citation. Scope describes how widespread the problem is: isolated, a pattern, or widespread. Severity describes the level of harm: potential for harm, no actual harm, actual harm, or immediate jeopardy. The combination of scope and severity determines the enforcement response.

A major decline or improvement in a resident’s physical or mental status that requires a new comprehensive MDS assessment and care plan revision. Federal regulation defines specific triggers. Facilities that fail to recognize and document significant changes miss required assessments and create gaps in the medical record.

Medical services that require the expertise of a licensed professional such as a registered nurse, physical therapist, or speech therapist. Medicare Part A covers skilled nursing facility stays only when skilled care is being provided and the resident is making measurable progress toward defined goals.

A facility certified by CMS to provide skilled nursing and rehabilitative care and authorized to bill Medicare Part A. Being in a Medicare-certified SNF does not automatically mean a resident is receiving Medicare-covered skilled care. These are two separate determinations.

A designation given by CMS to nursing homes with a persistent history of serious quality and safety problems. SFF facilities receive more frequent surveys and enhanced federal oversight. CMS also identifies SFF Candidates, which are facilities approaching this threshold. Both lists are publicly available on the CMS website.

The inspection process CMS uses to evaluate whether nursing facilities comply with federal regulations. Standard surveys occur roughly every 15 months. Complaint surveys are triggered by individual reports. Survey results, including deficiency citations and plans of correction, are public and available on the CMS Care Compare website.

The record of wound care, therapy, turning and repositioning schedules, and other ordered treatments. Like the MAR, the TAR should reflect what was actually done, when, and by whom. Gaps in the TAR or repetitive template entries without individualized notes indicate that documented care may not have been provided.

Physical and psychological deterioration that can result from relocating a frail elderly person from a familiar environment, particularly for those with dementia. Facilities may initiate transfer as retaliation after a family files a complaint. Federal law prohibits involuntary transfer or discharge except under specific circumstances and requires formal written notice.

A pressure injury where the base is covered by slough or eschar, making it impossible to determine the true depth and stage. Unstageable wounds indicate advanced tissue damage that developed over time. A new unstageable wound in a long-term resident requires investigation of repositioning and skin monitoring practices in the weeks before it became visible.

A bacterial infection of the urinary tract, extremely common in nursing home residents, particularly women and catheterized residents. In residents with dementia, a UTI may present only as sudden behavioral change or increased confusion, without the classic urinary symptoms that would alert staff. UTIs are frequently misdiagnosed, undertreated, or overtreated in nursing home settings.

A medication or treatment order communicated by a physician to nursing staff by phone or in person, documented by the nurse and signed by the physician within a required timeframe. Verbal orders without timely physician countersignature represent a compliance gap and create documentation vulnerabilities in legal proceedings.

Defined by CMS as loss of 5% or more of body weight in one month, or 10% or more in six months. Significant weight loss is a tracked quality measure and a common indicator of malnutrition and neglect. Facilities are required to assess the cause, notify the physician and family, and update the care plan.

A legal claim brought when a person dies as a result of another party’s negligence, recklessness, or wrongful act. In nursing home cases, wrongful death claims typically allege that the facility’s failure to provide adequate care directly caused or contributed to the resident’s death. State statutes of limitations determine how long families have to file.