Windsor Gardens Convalescent Hospital

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

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

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

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

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

Provide and implement an infection prevention and control program.

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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

Keep residents' personal and medical records private and confidential.

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Ensure each resident receives an accurate assessment.

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

Assist a resident in gaining access to vision and hearing services.

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

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

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.

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 r…

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

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

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

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 sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Ensure services provided by the nursing facility meet professional standards of quality.

Reasonably accommodate the needs and preferences of each resident.

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

Ensure each resident receives an accurate assessment.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

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

Ensure that residents are fully informed and understand their health status, care and treatments.

Reasonably accommodate the needs and preferences of each resident.

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

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

Assist a resident in gaining access to vision and hearing services.

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

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

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…

Ensure medication error rates are not 5 percent or greater.

Ensure that residents are free from significant medication errors.

Provide and implement an infection prevention and control program.

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Ensure that residents are free from significant medication errors.

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.

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

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

Provide and implement an infection prevention and control program.

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

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.

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

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

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

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

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.