GRACE HEALTHCARE CENTER

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

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.

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

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Provide and implement an infection prevention and control program.

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

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

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

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

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

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

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Keep all essential equipment working safely.

Provide and implement an infection prevention and control program.

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.

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

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.

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

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.

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.

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

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

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.

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

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

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

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

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.

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

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Provide and implement an infection prevention and control program.

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 each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

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

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.

Ensure medication error rates are not 5 percent or greater.

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.

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

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

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

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.

Assure that each resident’s assessment is updated at least once every 3 months.

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

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

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

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

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

Ensure that residents are free from significant medication errors.

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 resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Provide and implement an infection prevention and control program.

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.

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 each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Ensure medication error rates are not 5 percent or greater.

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.

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.