Custer Care and Rehab Center

Have a plan that describes the process for conducting QAPI and QAA activities.

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

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

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

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

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.

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Provide and implement an infection prevention and control program.

Assess the resident when there is a significant change in condition

Ensure each resident receives an accurate assessment.

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

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

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

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

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 r…

Post nurse staffing information every day.

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.