COLONIAL PARK MANOR, LLC

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.

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.

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 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.

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.

Assess the resident when there is a significant change in condition

Ensure each resident receives an accurate assessment.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

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

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

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Provide and implement an infection prevention and control program.

Keep residents' personal and medical records private and confidential.

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

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.

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

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

Assess the resident when there is a significant change in condition

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.

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

PASARR screening for Mental disorders or Intellectual Disabilities

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.

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

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

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.

Provide timely, quality laboratory services/tests to meet the needs of residents.

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

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

Provide and implement an infection prevention and control program.

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

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

Completely assess the resident at least every twelve months.

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.