Alhambra Convalescent Hospital

Plan the resident's discharge to meet the resident's goals and needs.

Provide care and assistance to perform activities of daily living for any resident who is unable.

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

Ensure residents have reasonable access to and privacy in their use of communication methods.

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.

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.

Protect each resident from the wrongful use of the resident's belongings or money.

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

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.

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

Provide care and assistance to perform activities of daily living for any resident who is unable.

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

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.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Provide and implement an infection prevention and control program.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

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

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Assure that each resident’s assessment is updated at least once every 3 months.

PASARR screening for Mental disorders or Intellectual Disabilities

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 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.

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.

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.

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

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Ensure staff are vaccinated for COVID-19

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Ensure that residents are free from significant medication errors.

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.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Keep residents' personal and medical records private and confidential.

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

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

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 medication error rates are not 5 percent or greater.

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 meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Provide and implement an infection prevention and control program.

Keep all essential equipment working safely.

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

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

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

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Maintain comfortable sound levels.

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

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

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.