Amethyst Health of Brown Deer

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

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

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

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

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

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

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

Provide and implement an infection prevention and control program.

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

Dispose of garbage and refuse properly.

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

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.

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

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Provide care or services that was trauma informed and/or culturally competent.

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

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

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

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

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

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

Ensure each resident receives an accurate assessment.

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

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

Respond appropriately to all alleged violations.

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

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

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.

Allow residents to self-administer drugs if determined clinically appropriate.

Provide and implement an infection prevention and control program.

Provide or get specialized rehabilitative services as required for a resident.

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

Post nurse staffing information every day.

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.

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.

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

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 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.

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

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

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

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

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

Provide training in compliance and ethics.

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

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

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

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

Develop, implement, and/or maintain an effective training program for all new and existing staff members.

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.

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

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 pressure ulcer care and prevent new ulcers from developing.

Provide and implement an infection prevention and control program.

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

Post nurse staffing information every day.

Provide safe, appropriate pain management for a resident who requires such services.

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

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

PASARR screening for Mental disorders or Intellectual Disabilities

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

Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Provide and implement an infection prevention and control program.

Provide or obtain dental services for each resident.

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.

Ensure medication error rates are not 5 percent or greater.

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

Provide safe, appropriate dialysis care/services for a resident who requires such services.

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

Provide appropriate foot care.

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

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

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

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

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