Luther Haven

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

Ensure each resident receives an accurate assessment.

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.

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

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.

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

Respond appropriately to all alleged violations.

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

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.

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

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

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

Provide and implement an infection prevention and control program.

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

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.

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 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.

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

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