NANCY HART NURSING CENTER

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

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

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

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

Keep residents' personal and medical records private and confidential.

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.

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

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

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.

Implement a program that monitors antibiotic use.

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.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Assure the security of all personal funds of residents deposited with the facility.

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

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.

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.

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

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.

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Ensure the activities program is directed by a qualified professional.

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

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.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

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

Assure that each resident’s assessment is updated at least once every 3 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 appropriate pressure ulcer care and prevent new ulcers from developing.

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

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.

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

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

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

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

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

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

Develop policies and procedures for influenza and pneumococcal immunizations.