GRAND MANOR NURSING & REHABILITATION CENTER

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

Ensure that residents are free from significant medication errors.

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

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

Keep all essential equipment working safely.

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.

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

Implement a program that monitors antibiotic use.

Provide and implement an infection prevention and control program.

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.

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

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

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

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

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.

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

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

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

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

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

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

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

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

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.

Ensure each resident receives an accurate assessment.

Respond appropriately to all alleged violations.

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

Keep residents' personal and medical records private and confidential.

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

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

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

Provide and implement an infection prevention and control program.

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

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

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.

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

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

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.

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

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

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

Ensure each resident receives an accurate assessment.

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 and the facility must promote and facilitate resident self-determination through support of resident choice.

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

Provide appropriate foot care.

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

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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