Custer Care and Rehab Center

Respond appropriately to all alleged violations.

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

Provide medically-related social services to help each resident achieve the highest possible quality of life.

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

Assess the resident when there is a significant change in condition

Ensure each resident receives an accurate assessment.

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

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

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

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

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.

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.

Post nurse staffing information every day.

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.

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

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

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

Provide and implement an infection prevention and control program.

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.