Pope Nursing Home

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

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

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Provide care or services that was trauma informed and/or culturally competent.

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.

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.

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.

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.

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.

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

Provide and implement an infection prevention and control program.

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

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

Give the resident's representative the ability to exercise the resident's rights.

Ensure that residents are fully informed and understand their health status, care and treatments.

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

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

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.

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.

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

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 to prevent abuse, neglect, and theft.

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.

Develop and implement 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.

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

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.

Observe each nurse aide's job performance and give regular training.

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.

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

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.

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

Provide and implement an infection prevention and control program.

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

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

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

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 and implement an infection prevention and control program.

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

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

Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.

Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

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

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

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%.

Train all employees on what to do in an emergency, and carry out unannounced staff drills.