VICTORY HEALTH & REHABILITATION CENTER

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

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

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.

Provide and implement an infection prevention and control program.

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

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.

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

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

Reasonably accommodate the needs and preferences of each resident.

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 manage his or her financial affairs.

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

Ensure each resident receives an accurate assessment.

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

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

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

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.

Provide or obtain dental services for each resident.

Provide or get specialized rehabilitative services as required for a resident.

Provide and implement an infection prevention and control program.

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.

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

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

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

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.

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

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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

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

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

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.

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.

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Provide routine and 24-hour emergency dental care for each resident.

Provide or get specialized rehabilitative services as required for a resident.

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

Provide and implement an infection prevention and control program.

Perform COVID19 testing on residents and staff.

Ensure staff are vaccinated for COVID-19

Reasonably accommodate the needs and preferences of each resident.

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

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.

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

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

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.

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.

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

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.

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

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

Ensure medication error rates are not 5 percent or greater.

Keep residents' personal and medical records private and confidential.

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.

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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

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

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

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

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

Respond appropriately to all alleged violations.

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

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

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

Provide and implement an infection prevention and control program.

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

Perform COVID19 testing on residents and staff.

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

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

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

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

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.

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

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.

Provide and implement an infection prevention and control program.

Provide and implement an infection prevention and control program.

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

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

Reasonably accommodate the needs and preferences of each resident.

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

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.

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

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.

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.

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.

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

PASARR screening for Mental disorders or Intellectual Disabilities

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

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 activities to meet all resident's needs.

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

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

Keep residents' personal and medical records private and confidential.

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.

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.

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

Ensure each resident receives an accurate assessment.

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

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.

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

Provide activities to meet all resident's needs.

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

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.

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

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

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