SPRING HILL REHABILITATION AND NURSING CENTER

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

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

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

Respond appropriately to all alleged violations.

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

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

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

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.

Keep all essential equipment working safely.

Provide and implement an infection prevention and control program.

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.

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

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

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

Reasonably accommodate the needs and preferences of each resident.

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

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.

Provide and implement an infection prevention and control program.

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

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

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

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 a dignified existence, self-determination, communication, and to exercise his or her rights.

Provide and implement an infection prevention and control program.

Ensure that residents are free from significant medication errors.

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

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 safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Reasonably accommodate the needs and preferences of each resident.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Keep all essential equipment working safely.

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

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

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

Hire a qualified full-time social worker in a facility with more than 120 beds.

Provide or get specialized rehabilitative services as required for a resident.

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

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.

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

Provide medically-related social services to help each resident achieve the highest possible quality of life.

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

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.

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

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.

Provide safe, appropriate pain management 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.

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

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

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.

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.

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

Respond appropriately to all alleged violations.

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.

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

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

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Ensure that residents are free from significant medication errors.

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

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.

Plan the resident's discharge to meet the resident's goals and needs.

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

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 residents are free from significant medication errors.

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

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

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

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

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

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

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

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

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 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 pressure ulcer care and prevent new ulcers from developing.

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.

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

Reasonably accommodate the needs and preferences of each resident.

Allow residents to self-administer drugs if determined clinically appropriate.

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 nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

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

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.

Provide and implement an infection prevention and control program.

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

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

Respond appropriately to all alleged violations.