🔎 Southeast Health Care Center

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

Provide and implement an infection prevention and control program.

Scope/Severity: D

Implement a program that monitors antibiotic use.

Scope/Severity: D

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

Scope/Severity: D

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.

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

Respond appropriately to all alleged violations.

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: B

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Scope/Severity: B

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

Scope/Severity: B

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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.

Scope/Severity: C

Post nurse staffing information every day.

Scope/Severity: D

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

Scope/Severity: D

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.

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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.

Scope/Severity: D

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Scope/Severity: D

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.

Scope/Severity: D

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

Scope/Severity: B

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

Scope/Severity: D

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

Scope/Severity: B

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

Scope/Severity: B

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.

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

Provide activities to meet all resident's needs.

Scope/Severity: D

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

Scope/Severity: D

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

Scope/Severity: D

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.

Scope/Severity: D

Ensure medication error rates are not 5 percent or greater.

Scope/Severity: D

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.

Scope/Severity: D

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.