Country Gardens Health and Rehabilitation Center

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

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

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

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

Keep residents' personal and medical records private and confidential.

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.

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

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

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

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

Ensure medication error rates are not 5 percent or greater.

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

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

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.

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

Provide and implement an infection prevention and control program.

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

Ensure each resident receives an accurate assessment.

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

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

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

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

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

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

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

Ensure that residents are free from significant medication errors.

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

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

Keep residents' personal and medical records private and confidential.

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

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

Provide activities to meet all resident's needs.

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

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

Provide and implement an infection prevention and control program.

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

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

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Provide training in compliance and ethics.

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

Ensure the activities program is directed by a qualified professional.

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

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

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

Ensure each resident receives an accurate assessment.

Ensure a qualified health professional conducts resident assessments.

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

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

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

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

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.

Provide and implement an infection prevention and control program.

Perform COVID19 testing on residents and staff.