AXIOM HEALTHCARE OF MOUNT VERNON

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

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

Infection Control Deficiencies

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

Resident Rights Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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.

Quality of Life and Care Deficiencies

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

Nursing and Physician Services Deficiencies

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

Nursing and Physician Services Deficiencies

Provide or arrange emergency care by a doctor 24 hours a day.

Nursing and Physician Services Deficiencies

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

Nursing and Physician Services Deficiencies

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

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

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

Nutrition and Dietary Deficiencies

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

Administration Deficiencies

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

Administration Deficiencies

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

Administration Deficiencies

Provide training in compliance and ethics.

Administration Deficiencies

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

Nursing and Physician Services Deficiencies

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

Administration Deficiencies

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

Resident Rights Deficiencies

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.

Resident Rights Deficiencies

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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.

Nursing and Physician Services Deficiencies

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.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

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

Nutrition and Dietary Deficiencies

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

Administration Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Nutrition and Dietary Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Nutrition and Dietary Deficiencies

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Nutrition and Dietary Deficiencies

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

Nursing and Physician Services Deficiencies

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.

Nursing and Physician Services Deficiencies

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.

Resident Rights Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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.

Pharmacy Service Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Nutrition and Dietary Deficiencies

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

Nutrition and Dietary Deficiencies