COUNTRY GARDENS HEALTH AND REHABILITATION CENTER

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

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

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

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Provide and implement an infection prevention and control program.

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

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

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

Ensure medication error rates are not 5 percent or greater.

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.

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

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

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 residents' personal and medical records private and confidential.

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

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

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

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.

Provide and implement an infection prevention and control program.

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.

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

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

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.

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

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

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

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

Ensure each resident receives an accurate assessment.

Keep residents' personal and medical records private and confidential.

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 organize and participate in resident/family groups in the facility.