St. Andrew Post-acute Rehabilitation Center

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.

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

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

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

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

Provide safe, appropriate dialysis care/services for a resident who requires such services.

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 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.

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.

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

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

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.

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

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

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.

Dispose of garbage and refuse properly.

Provide and implement an infection prevention and control program.

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.

Ensure each resident receives an accurate assessment.

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

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.

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Provide and implement an infection prevention and control program.

Respond appropriately to all alleged violations.

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

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

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.

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

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

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

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

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

Protect each resident from mistreatment, neglect and misappropriation of personal property.

1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

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

Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident .