MULTY MEDICAL SKILLED NURSING FACILITY

Put firmly secured handrails on each side of hallways.

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

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

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.

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.

Post nurse staffing information every day.

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.

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

Keep all essential equipment working safely.

Have a Compliance and Ethics Program.

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.

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

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

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

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.

Dispose of garbage and refuse properly.

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

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

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

Provide routine and 24-hour emergency dental care for each resident.

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

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

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

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

Post nurse staffing information every day.

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

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 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 appropriate care/assistance for a resident with a prosthesis.

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

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Provide appropriate foot care.

Assist a resident in gaining access to vision and hearing services.

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

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

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.

Prepare residents for a safe transfer or discharge from the nursing home.

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.

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.

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

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

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

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

Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials.

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.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

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

Provide information about how to apply for and use Medicare and Medicaid benefits.

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.

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

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

The resident has the right to receive notices in a format and a language he or she understands.

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Give residents a notice of rights, rules, services and charges.

Honor the resident's right to manage his or her financial affairs.

1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.

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

Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Provide immediate access to any resident.

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

Protect a residents' right to refuse some types of non-requested transfers within the nursing home.

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Reasonably accommodate the needs and preferences of each resident.

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

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

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