SERENITY HILL NURSING CENTER

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

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.

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

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.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Provide and implement an infection prevention and control program.

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

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

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.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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

Provide and implement an infection prevention and control program.

Report COVID19 data to residents and families.

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.

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.

Perform COVID19 testing on residents and staff.

Provide and implement an infection prevention and control program.

Assess the resident when there is a significant change in condition

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 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.

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.

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

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

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

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

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

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

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.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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.

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

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

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

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.

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

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 residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.

Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances.

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.

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

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

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