East Troy Manor

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

Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

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

Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Provide training in compliance and ethics.

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Post nurse staffing information every day.

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

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

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

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

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.

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

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

Respond appropriately to all alleged violations.

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.

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

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 appropriate pressure ulcer care and prevent new ulcers from developing.

Provide and implement an infection prevention and control program.

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

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

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.

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 medication error rates are not 5 percent or greater.