Amethyst Health of Brown Deer

Provide and implement an infection prevention and control program.

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

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

Ensure that residents are free from significant medication errors.

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 safe and appropriate respiratory care for a resident when needed.

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

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

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.

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

Dispose of garbage and refuse properly.

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

Provide and implement an infection prevention and control program.

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

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

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.

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.

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

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

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

Ensure each resident receives an accurate assessment.

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

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

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

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

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

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

Respond appropriately to all alleged violations.

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

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

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 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.

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

Post nurse staffing information every day.

Provide and implement an infection prevention and control program.

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.

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

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

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

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

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

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

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

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

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

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

Provide training in compliance and ethics.

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

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

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.

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

Post nurse staffing information every day.

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

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.

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

PASARR screening for Mental disorders or Intellectual Disabilities

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

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

Ensure medication error rates are not 5 percent or greater.

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.

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

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 or obtain dental services for each resident.

Provide and implement an infection prevention and control program.

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

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

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

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

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

Provide appropriate foot care.

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

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

Ensure medication error rates are not 5 percent or greater.