WEST SIDE HOUSE LTC FACILITY

Assess the resident when there is a significant change in condition

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 medication error rates are not 5 percent or greater.

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.

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

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

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

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

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

Assess the resident when there is a significant change in condition

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.

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

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

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Post nurse staffing information every day.

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

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.

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Make sure that a working call system is available in each resident's bathroom and bathing area.

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

Provide activities to meet all resident's needs.

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

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

Ensure that residents are free from significant medication errors.

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.

Make sure that a working call system is available in each resident's bathroom and bathing area.

Provide and implement an infection prevention and control program.

Perform COVID19 testing on residents and staff.

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

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

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 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.

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

Ensure that residents are free from significant medication errors.

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

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

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

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.

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

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

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

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

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.

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

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.

Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.

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

Respond appropriately to all alleged violations.

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

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.

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.

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.

Provide timely, quality laboratory services/tests to meet the needs of residents.

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

Try to resolve each resident's complaints quickly.

Protect each resident from all abuse, physical punishment, and involuntary separation from others.

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

Allow residents to easily view the results of the nursing home's most recent inspection.

Keep each resident free from physical restraints, unless needed for medical treatment.

Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

Completely assess the resident at least every twelve months.

Ensure each resident receives an accurate assessment by a qualified health professional.

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

Provide care by qualified persons according to each resident's written plan of care.

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

Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.