CREEKSIDE CENTER FOR REHABILITATION AND NURSING

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.

Respond appropriately to all alleged violations.

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

Provide and implement an infection prevention and control program.

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

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

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

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

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

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

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

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

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

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.

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

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.

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

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

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

Post nurse staffing information every day.

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

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.

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

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

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

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

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

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 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.

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

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

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

Assess the resident when there is a significant change in condition

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.

Respond appropriately to all alleged violations.

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.

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.

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.

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

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

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.

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

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

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

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

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.

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.

Post nurse staffing information every day.

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

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

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.

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

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

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.

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

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.

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

Reasonably accommodate the needs and preferences of each resident.

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.

Provide routine and 24-hour emergency dental care for each resident.

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

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.

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 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.

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.

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

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

Honor each resident's preferences, choices, values and beliefs.

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.

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

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

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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Reasonably accommodate the needs and preferences of each resident.