AUTUMN LAKE HEALTHCARE AT ALICE MANOR

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.

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

Provide safe, appropriate pain management for a resident who requires such services.

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

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 that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

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

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

Provide or obtain dental services for each resident.

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.

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

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.

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

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

Respond appropriately to all alleged violations.

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.

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

Prepare residents for a safe transfer or discharge from the nursing home.

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Ensure each resident receives an accurate assessment.

PASARR screening for Mental disorders or Intellectual Disabilities

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

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

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Post nurse staffing information every day.

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.

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

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

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.

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.

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.

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

1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.

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.

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

Give residents a notice of rights, rules, services and charges.

1) Protect current or future residents from giving up their Medicaid or Medicare benefits; or 2) follow federal rules for admissions.

Provide activities to meet the interests and needs of each resident.

Conduct initial and periodic assessments of each resident's functional capacity.

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

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

Provide necessary care and services to maintain or improve the highest well being of each resident .

Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing.

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

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

Ensure residents maintain acceptable nutritional status.

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.

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

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

Have enough outside ventilation via a window or mechanical ventilation, or both.

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

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