Prevent avoidable declines in functioning or functional level.
Managing risk factors to the extent possible.
Addressing ways to preserve and build upon resident strengths.
Applying current standards of practice in the care planning process.
Evaluate care with measurable objectives, timetables, and care outcomes for the resident.
Respect resident’s right to decline treatment.
Offer alternative treatments as applicable.
Use an interdisciplinary approach.
Involve the resident, family, and other resident representatives.
Assessing and planning care for resident’s medical, nursing, mental, and psychosocial needs.
Involve direct care staff with care planning process.
Address additional issues relevant to meeting the resident’s needs. (Page 4–11).