Glenoaks Convalescent Hospital

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

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.

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

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

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

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

Provide and implement an infection prevention and control program.

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

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.

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

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.

Post nurse staffing information every day.

Ensure that residents are free from significant medication errors.

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 that each resident is free from the use of physical restraints, unless needed for medical treatment.

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.

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.

Reasonably accommodate the needs and preferences of each resident.

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

Provide activities to meet all resident's needs.

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

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.

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

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

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

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

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.

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

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 policies and procedures for flu and pneumonia vaccinations.

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

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

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

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

Prepare residents for a safe transfer or discharge from the nursing home.

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

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

Reasonably accommodate the needs and preferences of each resident.

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

Give residents a notice of rights, rules, services and charges.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

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.

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

Provide activities to meet all resident's needs.

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

Assist a resident in gaining access to vision and hearing services.

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 feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

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.

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.

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

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

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.

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

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

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

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

Provide and implement an infection prevention and control program.

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

Provide and implement an infection prevention and control program.

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.

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

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

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

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.

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 that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

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.

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

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

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.

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

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

Provide and implement an infection prevention and control program.

Implement a program that monitors antibiotic use.

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Provide and implement an infection prevention and control program.

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

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

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

Respond appropriately to all alleged violations.

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.

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.

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

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

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

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 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.

Provide and implement an infection prevention and control program.

Keep all essential equipment working safely.

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

Keep residents' personal and medical records private and confidential.

Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.

Develop 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.

Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay.

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

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.

Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.

Ensure residents maintain acceptable nutritional status.

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.

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.

Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

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

Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.

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.