COUNTRY LANE GARDENS REHAB & NURSING CTR

Ensure that residents are free from significant medication errors.

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

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

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

Respond appropriately to all alleged violations.

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

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

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.

Have a plan that describes the process for conducting QAPI and QAA activities.

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

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

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.

Ensure that residents are free from significant medication errors.

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

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.

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

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

Provide appropriate foot care.

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.

Respond appropriately to all alleged violations.

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

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

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

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

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 organize and participate in resident/family groups in the facility.

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

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

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.

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

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.

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

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

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

Respond appropriately to all alleged violations.

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

Implement a program that monitors antibiotic use.

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.

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

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’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.

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

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

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

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.

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 be treated with respect and dignity and to retain and use personal possessions.

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

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

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

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

Respond appropriately to all alleged violations.

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

Make sure that a working call system is available in each resident's bathroom and bathing area.

Ensure staff are vaccinated for COVID-19

Implement a program that monitors antibiotic use.

Provide and implement an infection prevention and control program.

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

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

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

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

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

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.

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

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

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

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

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.

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

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

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

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

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.

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

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 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.

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.

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.

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

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.

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

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

PASARR screening for Mental disorders or Intellectual Disabilities

Respond appropriately to all alleged violations.

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

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

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.

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

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.

Honor the resident's right to organize and participate in resident/family groups in the facility.

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

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