LAYHILL NURSING AND REHABILITATION CENTER

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

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

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

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

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

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

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

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

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

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

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

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

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

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

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

Post nurse staffing information every day.

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

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.

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

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 activities to meet all resident's needs.

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

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

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

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.

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

PASARR screening for Mental disorders or Intellectual Disabilities

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

Provide and implement an infection prevention and control program.

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

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

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.

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 residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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.

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

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

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

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

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

Respond appropriately to all alleged violations.

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

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.

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

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.

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 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.

Ensure each resident receives an accurate assessment.

Keep all essential equipment working safely.

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

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 medication error rates are not 5 percent or greater.

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

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.