Tuff Memorial Home

Ensure each resident receives an accurate assessment.

Implement a program that monitors antibiotic use.

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

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

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.

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

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

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

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

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

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.

Ensure medication error rates are not 5 percent or greater.

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.

Report COVID19 data to residents and families.

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

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.

Provide and implement an infection prevention and control program.

Provide and implement an infection prevention and control program.

Provide and implement an infection prevention and control program.

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

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.

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

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

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

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.

Provide and implement an infection prevention and control program.

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

Listen to the resident groups and act on their complaints and suggestions that affect resident care and life.

Maintain comfortable and safe temperature levels.

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.

Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

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

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.