ST LUKE'S NURSING AND REHABILITATION

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

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

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

Provide activities to meet all resident's needs.

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

Ensure residents have reasonable access to and privacy in their use of communication methods.

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Provide and implement an infection prevention and control program.

Ensure that residents are free from significant medication errors.

Ensure medication error rates are not 5 percent or greater.

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Ensure each resident receives an accurate assessment.

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.

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

Have enough outside ventilation via a window or mechanical ventilation, or both.

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.

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.

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

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