All citations for Bartow Center

QAPI/QAA IMPROVEMENT ACTIVITIES

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.

PASARR screening for Mental disorders or Intellectual Disabilities

Honor the resident''s right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

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

Provide safe and appropriate respiratory care for a resident when needed.

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.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Provide and implement an infection prevention and control program.

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

RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE

PHYSICAL ENVIRONMENT - SAFE, CLEAN, HOMELIKE

LABEL/STORE DRUGS AND BIOLOGICALS

INFECTION PREVENTION & CONTROL

RESIDENT GRIEVANCES AND COMPLAINTS

FOLLOW PHYSICIAN ORDERS

COMPREHENSIVE CARE PLANS

BOWEL/BLADDER INCONTINENCE, CATHETER, UTI

GRIEVANCES

PASARR SCREENING FOR MD & ID

DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

FIRE ALARM SYSTEM - TESTING AND MAINTENANCE Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

PORTABLE FIRE EXTINGUISHERS Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 18.3.5.12, 19.3.5.12, 9.9, and NFPA 10

SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE Subdivision of Building Spaces - Smoke Barrier Construction 2021 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3 through 19.3.7.5.2, 8.5 2021 NEW Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, in which case both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. (2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems. (3) The provisions of 8.5.6.5 and 8.5.7.2 shall not apply. 18.3.7.3 through 18.8.7.5.2, 8.5 For other than existing assemblies, where there is an accessible concealed floor, floor/ceiling, or attic space, fire barriers, smoke barriers, and smoke partitions shall be permanently identified with signs or stenciling in the concealed space and shall comply with all of the following: " (1) Be located in accessible concealed floor, floor/ceiling, or attic spaces. " (2) Be located within 15 ft (4572 mm) of the end of each wall and at intervals not exceeding 30 ft (9144 mm) measured horizontally along the wall or partition. " (3) Include lettering not less than 3 in. (76 mm) in height with a minimum 3?8 in. (9.5 mm) stroke in a contrasting color. " (4) Identify the wall type and its fire resistance rating, as applicable. 8.2.2.5

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

QUALITY OF CARE

RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE (l) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency.

BOWEL/BLADDER INCONTINENCE, CATHETER, UTI

MINIMUM NURSING STAFF 59A-4.108(4) In accordance with the requirements outlined in subsection 400.23(3)(a), F.S., the nursing home licensee must have sufficient nursing staff, on a 24-hour basis to provide nursing and related services to residents in order to maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. 400.23(3)(a)2 For purposes of this subsection, direct care staffing hours do not include time spent on nursing administration, activities program administration, staff development, staffing coordination, and the administrative portion of the minimum data set and care plan coordination for Medicaid. 400.23(3)(b)1. Each facility must determine its direct care staffing needs based on the facility assessment and the individual needs of a resident based on the resident's care plan. At a minimum, staffing must include, for each facility, the following requirements: a. A minimum weekly average of 3.6 hours of care by direct care staff per resident per day. As used in this sub-subparagraph, a week is defined as Sunday through Saturday. b. A minimum of 2.0 hours of direct care by a certified nursing assistant per resident per day. A facility may not staff below one certified nursing assistant per 20 residents. c. A minimum of 1.0 hour of direct care by a licensed nurse per resident per day. A facility may not staff below one licensed nurse per 40 residents. 2. Nursing assistants employed under s. 400.211(2) may be included in computing the hours of direct care provided by certified nursing assistants and may be included in computing the staffing ratio for certified nursing assistants if their job responsibilities include only nursing-assistant-related duties. 4. The agency must recognize the use of licensed nurses for compliance with minimum staffing requirements for certified nursing assistants if the nursing home facility otherwise meets the minimum staffi

LABEL/STORE DRUGS AND BIOLOGICALS §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

FOLLOW PHYSICIAN ORDERS All physician orders must be followed as prescribed, and if not followed, the reason must be recorded on the resident's medical record during that shift.

PHYSICAL ENVIRONMENT - SAFE, CLEAN, HOMELIKE 400.141(1)(h) FS Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 59A-4.122(1) FAC The licensee must provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible

REASONABLE ACCOMMODATIONS NEEDS/PREFERENCES §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

FREE OF MEDICATION ERROR RTS 5 PRCNT OR MORE §483.45(f) Medication Errors. The facility must ensure that its- §483.45(f)(1) Medication error rates are not 5 percent or greater;

RIGHT TO FILE GRIEVANCES (d) The right to present grievances on behalf of himself or herself or others to the staff or administrator of the facility, to governmental officials, or to any other person; to recommend changes in policies and services to facility personnel; and to join with other residents or individuals within or outside the facility to work for improvements in resident care, free from restraint, interference, coercion, discrimination, or reprisal. This right includes access to ombudsmen and advocates and the right to be a member of, to be active in, and to associate with advocacy or special interest groups. The right also includes the right to prompt efforts by the facility to resolve resident grievances, including grievances with respect to the behavior of other residents.

RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE (l) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency.

GRIEVANCES §483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through

ADL CARE PROVIDED FOR DEPENDENT RESIDENTS §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

FACILITY POLICIES REQUIRED (2) Each nursing home licensee must adopt, implement, and maintain written policies and procedures governing all services provided in the facility. (3) All policies and procedures must be reviewed at least annually and revised as needed with input from the facility Administrator, Medical Director, and Director of Nursing.

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

Provide timely, quality laboratory services/tests to meet the needs of residents.

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.

FOLLOW PHYSICIAN ORDERS All physician orders must be followed as prescribed, and if not followed, the reason must be recorded on the resident's medical record during that shift.

PHYSICAL ENVIRONMENT - SAFE, CLEAN, HOMELIKE 400.141(1)(h) FS Maintain the facility premises and equipment and conduct its operations in a safe and sanitary manner. 59A-4.122(1) FAC The licensee must provide a safe, clean, comfortable, and homelike environment, which allows the resident to use his or her personal belongings to the extent possible

RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE (l) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency.

NURSING HOME GUIDE POSTED (5) Every nursing home facility licensee shall: (a) Post, in a sufficient number of prominent positions in the nursing home so as to be accessible to all residents and to the general public: 2. A copy of all of the pages that list the facility in the most recent version of the Nursing Home Guide.