SQUIRREL HILL WELLNESS AND REHABILITATION CENTER

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.

Respond appropriately to all alleged violations.

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

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

Respond appropriately to all alleged violations.

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

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.

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

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

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.

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.

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.

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

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

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

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

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

Provide safe, appropriate dialysis care/services for a resident who requires such services.

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.

Ensure the activities program is directed by a qualified professional.

Provide activities to meet all resident's needs.

Ensure each resident receives an accurate 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.

Respond appropriately to all alleged violations.

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

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.

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

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.

Honor the resident's right to organize and participate in resident/family groups in the facility.

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

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

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

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

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

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.

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.

Provide training in compliance and ethics.

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.

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.

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

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

Implement a program that monitors antibiotic use.

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 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.

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.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

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

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

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.

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

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

Assist a resident in gaining access to vision and hearing services.

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.

Respond appropriately to all alleged violations.

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 voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

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.

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

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

Ensure the activities program is directed by a qualified professional.

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 each resident is free from the use of physical restraints, unless needed for medical treatment.

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

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

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Keep all essential equipment working safely.

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.

Ensure that residents are free from significant medication errors.

Ensure medication error rates are not 5 percent or greater.

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

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

Ensure the activities program is directed by a qualified professional.

Provide activities to meet all resident's needs.

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

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

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

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

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.

Ensure residents have reasonable access to and privacy in their use of communication methods.

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