Ascension Living - Lakeshore at Siena

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.

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

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

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

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

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Provide and implement an infection prevention and control program.

Implement a program that monitors antibiotic use.

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

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

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

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.

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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.

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

Respond appropriately to all alleged violations.

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

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.

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 safe and appropriate respiratory care for a resident when needed.

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.

Ensure medication error rates are not 5 percent or greater.

Post nurse staffing information every day.

Respond appropriately to all alleged violations.

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

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