BELAIR HEALTHCARE AND REHABILITATION CENTER

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.

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

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

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

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.

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

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

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

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.

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

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.

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

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

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.

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

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

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

Protect each resident from the wrongful use of the resident's belongings or money.

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

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.

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.

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.

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

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

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

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

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

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

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

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.

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

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

Reasonably accommodate the needs and preferences of each resident.

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.

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.

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

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

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

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.

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.

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

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

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.

Provide activities to meet all resident's needs.

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

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.

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

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.

Report COVID19 data to residents and families.

Perform COVID19 testing on residents and staff.

Ensure staff are vaccinated for COVID-19

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.

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

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

Respond appropriately to all alleged violations.

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

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.

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

Ensure that residents are free from significant medication errors.

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.

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

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

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.

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

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

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

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

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

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.

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

Post nurse staffing information every day.

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 each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

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

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Provide and implement an infection prevention and control program.

Implement a program that monitors antibiotic use.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Reasonably accommodate the needs and preferences of each resident.

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.

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

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

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

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.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

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

Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.

Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

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

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

Try to resolve each resident's complaints quickly.