Trinity Village Medical Center

Keep residents' personal and medical records private and confidential.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Ensure medication error rates are not 5 percent or greater.

Ensure that residents are free from significant medication errors.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Provide and implement an infection prevention and control program.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Provide safe and appropriate respiratory care for a resident when needed.

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Provide and implement an infection prevention and control program.

Honor the resident's right to organize and participate in resident/family groups in the facility.

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide enough food/fluids to maintain a resident's health.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Dispose of garbage and refuse properly.

Have a plan that describes the process for conducting QAPI and QAA activities.

Provide and implement an infection prevention and control program.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Respond appropriately to all alleged violations.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide enough food/fluids to maintain a resident's health.

Provide safe and appropriate respiratory care for a resident when needed.

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Provide and implement an infection prevention and control program.

Provide and implement an infection prevention and control program.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Dispose of garbage and refuse properly.

Provide and implement an infection prevention and control program.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Provide and implement an infection prevention and control program.

Ensure each resident receives an accurate assessment.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Provide safe and appropriate respiratory care for a resident when needed.

Ensure that residents are free from significant medication errors.

Provide and implement an infection prevention and control program.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Provide appropriate foot care.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide and implement an infection prevention and control program.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Provide safe and appropriate respiratory care for a resident when needed.

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

The resident has the right to receive notices in a format and a language he or she understands.

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Provide enough food/fluids to maintain a resident's health.

Ensure that residents are free from significant medication errors.

Keep residents' personal and medical records private and confidential.

Provide necessary care and services to maintain or improve the highest well being of each resident .

Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

Store, cook, and serve food in a safe and clean way.