North BAY Post Acute

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

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

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

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

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

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

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

Provide or obtain dental services for each resident.

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Have policies on smoking.

Ensure each resident receives an accurate assessment.

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.

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

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

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

Provide and implement an infection prevention and control program.

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

Respond appropriately to all alleged violations.

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

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

Ensure that residents are fully informed and understand their health status, care and treatments.

Reasonably accommodate the needs and preferences of each resident.

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.

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

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

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

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

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

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

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

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

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 that residents are free from significant medication errors.

Provide or obtain dental services for each resident.

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

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

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

Ensure each resident receives an accurate assessment.

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 a program that monitors antibiotic use.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

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.

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

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.

Ensure medication error rates are not 5 percent or greater.

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

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

Provide and implement an infection prevention and control program.

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

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

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

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

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.

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

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

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

Dispose of garbage and refuse properly.

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

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

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

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

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.

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

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

Assess the resident when there is a significant change in condition

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

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

Provide care or services that was trauma informed and/or culturally competent.

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.

Ensure that residents are fully informed and understand their health status, care and treatments.

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Ensure each resident receives an accurate assessment.

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

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

Ensure medication error rates are not 5 percent or greater.

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.

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

Provide and implement an infection prevention and control program.

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

Have policies on smoking.

Assure that each resident’s assessment is updated at least once every 3 months.

Provide activities to meet all resident's needs.

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.

Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.

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