Carvalho Grove Health and Rehabilitation Center

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

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.

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

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

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

Keep residents' personal and medical records private and confidential.

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

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

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.

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

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

Implement a program that monitors antibiotic use.

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.

Reasonably accommodate the needs and preferences of each resident.

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

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

Provide and implement an infection prevention and control program.

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

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

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

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

Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

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

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

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

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.

Provide and implement an infection prevention and control program.

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

Reasonably accommodate the needs and preferences of each resident.

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

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

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

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

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

Provide or obtain dental services for each resident.

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

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

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.