MOUNTAIN LAUREL REHABILITATION AND NURSING, RURAL RETREAT, VA — Violations & Inspection Reports

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 timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

Honor each resident's preferences, choices, values and beliefs.

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.

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 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.

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

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

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.

Dispose of garbage and refuse properly.

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

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

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

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

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

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

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

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

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.

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

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

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

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

Keep residents' personal and medical records private and confidential.

Provide and implement an infection prevention and control program.

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 doctor's orders for the resident's immediate care at the time the resident was admitted.

Ensure each resident receives an accurate assessment.

PASARR screening for Mental disorders or Intellectual Disabilities

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Provide activities to meet all resident's needs.

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.

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

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

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

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

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Provide safe and appropriate respiratory care for a resident when needed.

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

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

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

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

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

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

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

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

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 that residents are free from significant medication errors.

Post nurse staffing information every day.