EVERGREEN HEALTH AND REHABILITATION 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.

Provide and implement an infection prevention and control program.

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.

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

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

Ensure medication error rates are not 5 percent or greater.

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.

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

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 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.

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.

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.

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.

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

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

Ensure that residents are free from significant medication errors.

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

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

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

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

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

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.

Post nurse staffing information every day.

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

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.

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.

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.

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.

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.

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 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.

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.

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

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.

Ensure each resident receives an accurate assessment.

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.

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 a dignified existence, self-determination, communication, and to exercise his or her rights.