Hillcrest Manor Sanitarium

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

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 a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Assess the resident when there is a significant change in condition

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 pressure ulcer care and prevent new ulcers from developing.

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.

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

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

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

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

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

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

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.

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

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

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

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

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

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

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

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.

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

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

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

Provide or obtain dental services for each resident.

Provide and implement an infection prevention and control program.

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

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

Honor the resident's right to manage his or her financial affairs.

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.

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

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.

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

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

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

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

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

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

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.

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

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

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

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

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

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

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

Ensure each resident receives an accurate assessment by a qualified health professional.

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

Maintain 15 months of resident assessments in the resident's active clinical record.

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.

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.

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

Provide bedrooms that hold no more than 4 residents per room.

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

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

Keep complete, dated laboratory records in the resident's file.

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