PROVIDENCE LIVING CENTER

Put firmly secured handrails on each side of hallways.

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

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.

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

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

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.

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

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

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.

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.

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

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

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.

Ensure that residents are fully informed and understand their health status, care and treatments.

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.

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

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

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

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.

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

Provide or get specialized rehabilitative services as required for a resident.

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

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