Awe Kualawaache Care Center

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Provide and implement an infection prevention and control program.

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

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.

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.

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

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

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.

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

Ensure each resident receives an accurate assessment.

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

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.

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

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

Respond appropriately to all alleged violations.

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 each resident receives an accurate assessment.

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.

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

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

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

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.

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.

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.

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

Respond appropriately to all alleged violations.

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

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

Respond appropriately to all alleged violations.

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

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

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 each resident receives and the facility provides food prepared in a form designed to meet individual needs.

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.

Provide and implement an infection prevention and control program.

Implement a program that monitors antibiotic use.

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.

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

Ensure medication error rates are not 5 percent or greater.

Ensure that residents are free from significant medication errors.

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.

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.

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 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.

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.

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

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

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

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.

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

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.

Implement a program that monitors antibiotic use.

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

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

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

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

Try to resolve each resident's complaints quickly.

Conduct initial and periodic assessments of each resident's functional capacity.

Allow residents the right to participate in the planning or revision of care and treatment.

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

Provide necessary care and services to maintain or improve the highest well being of each resident .

Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.

Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.

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

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.

Make sure that special or therapeutic diets are ordered by the attending doctor.

Give or get specialized rehabilitative services per the patient's assessment or plan of care.

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

Have a program that investigates, controls and keeps infection from spreading.

Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident .

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility

Give or get quality laboratory services/tests in a timely manner to meet the needs of residents.

Quickly tell the resident's doctor the results of laboratory tests.

Help the resident with transportation to and from laboratory services outside of the facility.

Keep complete, dated laboratory records in the resident's file.