BRIA OF TRINITY VILLAGE

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

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.

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 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.

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

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

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Provide training in compliance and ethics.

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

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

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.

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

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 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 foot care.

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

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

Ensure each resident’s drug regimen must be free from unnecessary drugs.

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 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.

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

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.

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.

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 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.

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.

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 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.

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

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

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 dialysis care/services for a resident who requires such services.

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.

Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.

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

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

Ensure that residents are free from significant medication errors.

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.

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

Respond appropriately to all alleged violations.

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 safe and appropriate respiratory care for a resident when needed.

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.

Observe each nurse aide's job performance and give regular training.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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 staff that are licensed, certified, or registered in accordance with state laws.

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.

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

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.

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.

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

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.

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

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

Provide and implement an infection prevention and control program.

Provide and implement an infection prevention and control program.

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Respond appropriately to all alleged violations.

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

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

Employ staff that are licensed, certified, or registered in accordance with state laws.

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 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.

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.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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

Ensure each resident’s drug regimen must be free from unnecessary drugs.

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 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 each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

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.

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

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

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

Respond appropriately to all alleged violations.

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

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

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

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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Ensure medication error rates are not 5 percent or greater.

Ensure that residents are free from significant medication errors.

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

Provide and implement an infection prevention and control program.

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.

Keep residents' personal and medical records private and confidential.

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

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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

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

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.

Protect each resident from all abuse, physical punishment, and involuntary separation from others.

1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.

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

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.

Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.

Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.

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

Ensure residents maintain acceptable nutritional status.

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

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.

Have enough nurses to care for every resident in a way that maximizes the resident's well being.

Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

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

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

Keep all essential equipment working safely.

1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.