Spring Creek Healthcare Center

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

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

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

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

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

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.

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

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

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.

Provide and implement an infection prevention and control program.

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

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

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.

Keep signed and dated reports of x-rays and other diagnostic services in the residents record.

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

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

Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.

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

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

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.

Implement a program that monitors antibiotic use.

Provide and implement an infection prevention and control program.

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

Reasonably accommodate the needs and preferences of each resident.

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

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.

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

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.

PASARR screening for Mental disorders or Intellectual Disabilities

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

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

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

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

Post nurse staffing information every day.

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

Ensure that residents are free from significant medication errors.

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Keep complete, dated laboratory records in the resident's record.

Keep signed and dated reports of x-rays and other diagnostic services in the residents record.

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

Implement a program that monitors antibiotic use.

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

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

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

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

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 voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

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

Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.

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.

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

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

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

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

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

Perform COVID19 testing on residents and staff.

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.

Ensure staff are vaccinated for COVID-19

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

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

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.

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.

Provide and implement an infection prevention and control program.

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

Keep all essential equipment working safely.

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

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

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

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

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.

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

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 timely, quality laboratory services/tests to meet the needs of residents.

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

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

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

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

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

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

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.

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

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.

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

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

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

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

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

Respond appropriately to all alleged violations.

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

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