AURORA VALLEY CARE

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

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

Provide and implement an infection prevention and control program.

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

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.

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

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

Provide or obtain dental services for each resident.

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 that residents are free from significant medication errors.

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

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

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

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

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

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 foot care.

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

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

PASARR screening for Mental disorders or Intellectual Disabilities

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

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.

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

The resident has the right to receive notices in a format and a language he or she understands.

Give residents a notice of rights, rules, services and charges.

Ensure that residents are fully informed and understand their health status, care and treatments.

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

Provide or obtain dental services for each resident.

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

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.

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

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.

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.

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

Plan the resident's discharge to meet the resident's goals and needs.

Provide and implement an infection prevention and control program.

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

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

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 or obtain dental services for each resident.

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 that residents are free from significant medication errors.

Ensure medication error rates are not 5 percent or greater.

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

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

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

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

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.

Plan the resident's discharge to meet the resident's goals and needs.

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

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

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.

Keep residents' personal and medical records private and confidential.

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

Ensure that residents are fully informed and understand their health status, care and treatments.

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

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

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

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

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

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.

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

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

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

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

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

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.

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

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

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

Respond appropriately to all alleged violations.

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

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

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

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

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Implement a program that monitors antibiotic use.

Provide and implement an infection prevention and control program.

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.

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 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.

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

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

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

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

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.

Ensure each resident receives an accurate assessment.

Respond appropriately to all alleged violations.

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

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

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.