OLD SOUTHWEST HEALTH AND REHABILITATION

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

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.

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

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.

Keep complete, dated laboratory records in the resident's record.

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

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

Ensure that residents are free from significant medication errors.

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.

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.

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

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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.

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.

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.

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.

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

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

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

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

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

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.

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

Provide and implement an infection prevention and control program.

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

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.

Keep complete, dated laboratory records in the resident's record.

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

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

Ensure that residents are free from significant medication errors.

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 nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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

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

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 activities to meet all resident's needs.

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

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.

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.

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

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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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.

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

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 and the facility must promote and facilitate resident self-determination through support of resident choice.

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.

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.

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.

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

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 foot care.

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

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

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

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.

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.

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

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

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

PASARR screening for Mental disorders or Intellectual Disabilities

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.

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

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.

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

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

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

Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.

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

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.

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

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

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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.

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.

PASARR screening for Mental disorders or Intellectual Disabilities

Ensure each resident receives an accurate assessment.

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.

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