Luther Haven

Ensure each resident receives an accurate assessment.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

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.

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

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

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.

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

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

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

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.

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

Respond appropriately to all alleged violations.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

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.

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.

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

Provide and implement an infection prevention and control program.

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

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

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.

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.