SOUTHSIDE CARE CENTER

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

Ensure each resident receives an accurate assessment.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

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.

Plan the resident's discharge to meet the resident's goals and needs.

Provide activities to meet all resident's needs.

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

Provide care or services that was trauma informed and/or culturally competent.

Post nurse staffing information every day.

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.

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.

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.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

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.

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Provide and implement an infection prevention and control program.

Allow residents to self-administer drugs if determined clinically appropriate.

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 each resident receives an accurate assessment.

Provide activities to meet all resident's needs.

Provide care or services that was trauma informed and/or culturally competent.

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.

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 or obtain dental services for each resident.

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

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.

Provide and implement an infection prevention and control program.

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

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

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

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

Respond appropriately to all alleged violations.

Provide activities to meet all resident's needs.

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

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

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.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

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.

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

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

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

Provide and implement an infection prevention and control program.

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

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

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

Request a waiver if it can't meet the nurse staffing requirements.

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.

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

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

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

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

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.

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.

Plan the resident's discharge to meet the resident's goals and needs.

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

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

Request a waiver if it can't meet the nurse staffing requirements.

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

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 or obtain dental services for each resident.

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

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

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 organize and participate in resident/family groups in the facility.

Ensure residents have reasonable access to and privacy in their use of communication methods.

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

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

PASARR screening for Mental disorders or Intellectual Disabilities

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