ANNANDALE HEALTHCARE CENTER

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

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

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Provide and implement an infection prevention and control program.

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

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

Provide timely, quality laboratory services/tests to meet the needs of residents.

Ensure that residents are free from significant medication errors.

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

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

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

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

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

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

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

Provide activities to meet all resident's needs.

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

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

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

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

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

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

Ensure each resident receives an accurate assessment.

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

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

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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

Provide and implement an infection prevention and control program.

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

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Dispose of garbage and refuse properly.

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

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

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

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

Ensure each resident receives an accurate assessment.

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

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.

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.

Reasonably accommodate the needs and preferences of each resident.

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

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

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

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.

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

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

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

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

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

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

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