🔎 Sunset Villa Healthcare

Scope/Severity: E

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

Scope/Severity: E

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: F

Provide and implement an infection prevention and control program.

Scope/Severity: F

Implement a program that monitors antibiotic use.

Scope/Severity: E

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

Scope/Severity: E

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: G

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

Scope/Severity: E

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

Scope/Severity: G

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

Scope/Severity: F

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: G

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

Scope/Severity: E

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

Scope/Severity: E

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

Scope/Severity: E

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.

Scope/Severity: E

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: E

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

Scope/Severity: E

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

Scope/Severity: E

Provide activities to meet all resident's needs.

Scope/Severity: F

Ensure the activities program is directed by a qualified professional.

Scope/Severity: E

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

Scope/Severity: G

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

Scope/Severity: E

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

Scope/Severity: H

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

Scope/Severity: E

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: E

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: F

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

Scope/Severity: E

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

Scope/Severity: E

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

Scope/Severity: E

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

Scope/Severity: E

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

Scope/Severity: F

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

Scope/Severity: E

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.

Scope/Severity: F

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

Scope/Severity: E

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

Scope/Severity: F

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.

Scope/Severity: F

Post nurse staffing information every day.

Scope/Severity: E

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

Scope/Severity: F

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: E

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

Scope/Severity: E

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

Scope/Severity: F

Ensure residents have reasonable access to and privacy in their use of communication methods.

Scope/Severity: F

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

Scope/Severity: E

Observe each nurse aide's job performance and give regular training.

Scope/Severity: E

Post nurse staffing information every day.

Scope/Severity: E

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

Scope/Severity: E

Provide and implement an infection prevention and control program.

Scope/Severity: E

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: E

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

Scope/Severity: E

The resident has the right to receive notices in a format and a language he or she understands.

Scope/Severity: F

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

Scope/Severity: E

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Scope/Severity: F

Provide and implement an infection prevention and control program.

Scope/Severity: F

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