SOUTH MOUNTAIN REHAB CENTER

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.

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.

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

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

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.

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.

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

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

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 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.

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

PASARR screening for Mental disorders or Intellectual Disabilities

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.

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.

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.

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.

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

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.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 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 appropriate treatment and care according to orders, resident’s preferences and goals.

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.

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.

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.