St. Francis Convalescent Pavilion

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

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

Provide and implement an infection prevention and control program.

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

Respond appropriately to all alleged violations.

Ensure each resident receives an accurate assessment.

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

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Keep residents' personal and medical records private and confidential.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Ensure each resident receives an accurate assessment.

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

PASARR screening for Mental disorders or Intellectual Disabilities

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

Post nurse staffing information every day.

Provide and implement an infection prevention and control program.

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

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

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

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

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

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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

Assess the resident when there is a significant change in condition

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

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

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

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

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.

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Ensure that residents are free from significant medication errors.

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

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

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

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

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

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

Provide and implement an infection prevention and control program.

Report COVID19 data to residents and families.

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

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

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

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.

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.

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

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.

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

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

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

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

Provide and implement an infection prevention and control program.

Report COVID19 data to residents and families.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Allow residents to self-administer drugs if determined clinically appropriate.

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

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

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.

Provide and implement an infection prevention and control program.

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

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

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

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.

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

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

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

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

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

Ensure medication error rates are not 5 percent or greater.

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.

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

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

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.

Provide necessary care and services to maintain or improve the highest well being of each resident .

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

Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

Hire sufficient dietary support personnel.

Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.

Store, cook, and serve food in a safe and clean way.

Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Have a program that investigates, controls and keeps infection from spreading.

Keep all essential equipment working safely.

Train all employees on what to do in an emergency, and carry out unannounced staff drills.