BLUE POINT HEALTHCARE CENTER

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

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

Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

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

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

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

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

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

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

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.

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.

Have enough outside ventilation via a window or mechanical ventilation, or both.

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

Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.

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.

Dispose of garbage and refuse properly.

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

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 medication error rates are not 5 percent or greater.

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

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

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

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

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

Provide activities to meet all resident's needs.

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.

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.

Respond appropriately to all alleged violations.

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.

Reasonably accommodate the needs and preferences of each resident.

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

Put firmly secured handrails on each side of hallways.

Have enough backup water supply for essential areas of the nursing home.

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

Provide and implement an infection prevention and control program.

Hire a qualified full-time social worker in a facility with more than 120 beds.

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.

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

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

Provide or obtain dental services for each resident.

Ensure medication error rates are not 5 percent or greater.

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

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

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

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.

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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

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.

PASARR screening for Mental disorders or Intellectual Disabilities

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

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

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

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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.

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

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

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

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

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 safe and appropriate respiratory care for a resident when needed.

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.

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

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.