WINDSOR GARDENS CONVALESCENT HOSPITAL

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

Reasonably accommodate the needs and preferences of each resident.

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

Provide and implement an infection prevention and control program.

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

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

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.

Ensure that residents are free from significant medication errors.

Ensure medication error rates are not 5 percent or greater.

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

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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

Assist a resident in gaining access to vision and hearing services.

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

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Ensure each resident receives an accurate assessment.

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Reasonably accommodate the needs and preferences of each resident.

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

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Ensure that residents are free from significant medication errors.

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.

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Provide safe and appropriate respiratory care for a resident when needed.

Provide and implement an infection prevention and control program.

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

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.

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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

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

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

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

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

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

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

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

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.

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

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

Reasonably accommodate the needs and preferences of each resident.

Ensure that residents are free from significant medication errors.

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

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

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.

Post nurse staffing information every day.

Provide safe and appropriate respiratory care for a resident when needed.

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

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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

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

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.

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

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

Make sure that a working call system is available in each resident's bathroom and bathing area.

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

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

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

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

Respond appropriately to all alleged violations.

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

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

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