Five Counties Nursing Home

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

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.

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

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

Respond appropriately to all alleged violations.

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.

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

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

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

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.

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.

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.

Post nurse staffing information every day.

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

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

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

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Respond appropriately to all alleged violations.

Keep residents' personal and medical records private and confidential.

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

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

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

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

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

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.

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.