Northern Oaks Living & Rehabilitation Center

Review of facility policy titled Comprehensive Person-Centered Care Planning revised on 12/2023 reflected: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.6.

The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.Review of facility policy titled Fall Management System revised on 01/2022 reflected: 1. On admission, the Fall Risk Evaluation will be completed to determine his/her risk for sustaining a fall.2.

Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes.a.

The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk.3.

When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.4.

Review of the fall incident will include investigation to determine probable causal factors.5.

The investigation will be reviewed by the Inter Disciplinary Team.6.

Resident's care plan will be updated.

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