Country Villa Pavilion Nursing Center

Prepare residents for a safe transfer or discharge from the nursing home.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Provide medically-related social services to help each resident achieve the highest possible quality of life.

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

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

Reasonably accommodate the needs and preferences of each resident.

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.

PASARR screening for Mental disorders or Intellectual Disabilities

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

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

Assist a resident in gaining access to vision and hearing services.

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

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

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

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.

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 share a room with spouse or roommate of choice and receive written notice before a change is made.

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.

Ensure each resident receives an accurate assessment.

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

Post nurse staffing information every day.

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

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.

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

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

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.

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.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

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

Provide safe, appropriate pain management for a resident who requires such services.

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.

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

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 that residents are free from significant medication errors.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

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

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

Provide and implement an infection prevention and control program.

Provide and implement an infection prevention and control program.

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

Reasonably accommodate the needs and preferences of each resident.

Respond appropriately to all alleged violations.

Assure that each resident’s assessment is updated at least once every 3 months.

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

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

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

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

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.

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Dispose of garbage and refuse properly.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

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

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Ensure that residents are fully informed and understand their health status, care and treatments.

Ensure that residents are fully informed and understand their health status, care and treatments.

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.

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

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

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

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

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.

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

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Ensure each resident receives an accurate assessment.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Provide and implement an infection prevention and control program.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

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.

Ensure services provided by the nursing facility meet professional standards of quality.

Provide activities to meet all resident's needs.

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.

Provide and implement an infection prevention and control program.

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

Ensure services provided by the nursing facility meet professional standards of quality.

Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.

Ensure residents maintain acceptable nutritional status.

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

Provide bedrooms that hold no more than 4 residents per room.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Train all employees on what to do in an emergency, and carry out unannounced staff drills.