VILLA DEL RIO BELL GARDENS CA: Inspection Results (2024)

Inspection Results

Nursing HomesCaliforniaBell GardensVilla Del Rio

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Villa Del Rio has been cited for a total of 105 deficiencies since we began saving each survey. We believe it is worthwhile to show how things are and were. Some improve and some get worse. Rather than a snapshot, we take s longer view than most. A longer view, we believe, paints a better and more worthwhile picture. We start from them most recent and go back as you scroll down.

Tip: Surveys happen throughout the year and you may want to check with the location or here to see if more recent data is available for Villa Del Rio.

Since we bagan longer term (multi year tracking, numbers will naturally be higher than 3 (or so surverys).
There are 1244 nursing homes in California with a total of 104,457 deficiencies resulting in an average of 83.97 deficiencies per nursing home.

The following table describes how deficiencies are scored. An easy way to remember the severity of a deficiency's scope is that the further along in the alphabet (A through L) the scope value is, the more severe the deficiency is.
Additionally, A through F means no actual harm has happened.

VILLA DEL RIO BELL GARDENS CA: Inspection Results (2)


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Deficiency Cited, Scope, survery date, stems from a complaint, and Date of Correction

Provide and implement an infection prevention and control program.

Category:

Infection Control Deficiencies

Scope:

K

From Complaint:

Y

Standard:

N

Survey Date:

2023-09-28

Corrected:

2023-10-27

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Category:

Resident Rights Deficiencies

Scope:

D

From Complaint:

Y

Standard:

N

Survey Date:

2023-07-06

Corrected:

2023-07-27

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

Category:

Resident Rights Deficiencies

Scope:

D

From Complaint:

Y

Standard:

N

Survey Date:

2023-06-28

Corrected:

2023-07-21

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

Category:

Quality of Life and Care Deficiencies

Scope:

G

From Complaint:

Y

Standard:

N

Survey Date:

2023-06-28

Corrected:

2023-07-21

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Category:

Environmental Deficiencies

Scope:

F

From Complaint:

Y

Standard:

N

Survey Date:

2023-06-23

Corrected:

2023-07-22

Post nurse staffing information every day.

Category:

Nursing and Physician Services Deficiencies

Scope:

E

From Complaint:

Y

Standard:

N

Survey Date:

2023-04-10

Corrected:

2023-04-18

Post nurse staffing information every day.

Category:

Nursing and Physician Services Deficiencies

Scope:

E

From Complaint:

Y

Standard:

N

Survey Date:

2023-04-10

Corrected:

2023-04-18

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.

Category:

Resident Rights Deficiencies

Scope:

D

From Complaint:

Y

Standard:

N

Survey Date:

2022-12-22

Corrected:

2023-01-10

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.

Category:

Resident Rights Deficiencies

Scope:

D

From Complaint:

Y

Standard:

N

Survey Date:

2022-12-22

Corrected:

2023-01-10

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

N

Survey Date:

2022-03-18

Corrected:

2022-03-28

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

N

Survey Date:

2022-03-18

Corrected:

2022-03-28

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

Category:

Resident Rights Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

PASARR screening for Mental disorders or Intellectual Disabilities

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Quality of Life and Care Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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.

Category:

Pharmacy Service Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

Ensure medication error rates are not 5 percent or greater.

Category:

Pharmacy Service Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Nutrition and Dietary Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Category:

Administration Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Administration Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

Provide and implement an infection prevention and control program.

Category:

Infection Control Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Infection Control Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Resident Rights Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Corrected:

2022-03-08

PASARR screening for Mental disorders or Intellectual Disabilities

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Quality of Life and Care Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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.

Category:

Pharmacy Service Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

Ensure medication error rates are not 5 percent or greater.

Category:

Pharmacy Service Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Nutrition and Dietary Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

Category:

Administration Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Administration Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

Provide and implement an infection prevention and control program.

Category:

Infection Control Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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

Category:

Infection Control Deficiencies

Scope:

F

From Complaint:

N

Standard:

Y

Survey Date:

2022-02-11

Corrected:

2022-03-08

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.

Category:

Nursing and Physician Services Deficiencies

Scope:

D

From Complaint:

N

Standard:

N

Survey Date:

2021-09-21

Corrected:

2021-10-06

Provide and implement an infection prevention and control program.

Category:

Infection Control Deficiencies

Scope:

D

From Complaint:

N

Standard:

N

Survey Date:

2021-09-21

Corrected:

2021-10-06

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.

Category:

Nursing and Physician Services Deficiencies

Scope:

D

From Complaint:

N

Standard:

N

Survey Date:

2021-09-21

Corrected:

2021-10-06

Provide and implement an infection prevention and control program.

Category:

Infection Control Deficiencies

Scope:

D

From Complaint:

N

Standard:

N

Survey Date:

2021-09-21

Corrected:

2021-10-06

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

Category:

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Scope:

D

From Complaint:

Y

Standard:

N

Survey Date:

2021-07-23

Corrected:

2021-09-20

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

Category:

Quality of Life and Care Deficiencies

Scope:

J

From Complaint:

Y

Standard:

N

Survey Date:

2021-07-23

Corrected:

2021-08-09

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

Category:

Environmental Deficiencies

Scope:

E

From Complaint:

Y

Standard:

N

Survey Date:

2021-07-23

Corrected:

2021-08-09

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

Category:

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Scope:

D

From Complaint:

Y

Standard:

N

Survey Date:

2021-07-23

Corrected:

2021-09-20

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

Category:

Quality of Life and Care Deficiencies

Scope:

J

From Complaint:

Y

Standard:

N

Survey Date:

2021-07-23

Corrected:

2021-08-09

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

Category:

Environmental Deficiencies

Scope:

E

From Complaint:

Y

Standard:

N

Survey Date:

2021-07-23

Corrected:

2021-08-09

Provide and implement an infection prevention and control program.

Category:

Infection Control Deficiencies

Scope:

E

From Complaint:

Y

Standard:

N

Survey Date:

2020-11-20

Corrected:

2020-12-14

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

Category:

Infection Control Deficiencies

Scope:

E

From Complaint:

Y

Standard:

N

Survey Date:

2020-11-20

Corrected:

2020-12-14

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Category:

Resident Rights Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

Ensure each resident receives an accurate assessment.

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Quality of Life and Care Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Quality of Life and Care Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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.

Category:

Nursing and Physician Services Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Pharmacy Service Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Pharmacy Service Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Category:

Nutrition and Dietary Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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.

Category:

Nutrition and Dietary Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Category:

Resident Rights Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

Ensure each resident receives an accurate assessment.

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Quality of Life and Care Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Quality of Life and Care Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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.

Category:

Nursing and Physician Services Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Pharmacy Service Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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

Category:

Pharmacy Service Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Category:

Nutrition and Dietary Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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.

Category:

Nutrition and Dietary Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2019-08-15

Corrected:

2019-09-19

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.

Category:

Resident Rights Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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.

Category:

Pharmacy Service Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

Ensure medication error rates are not 5 percent or greater.

Category:

Pharmacy Service Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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.

Category:

Pharmacy Service Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Category:

Administration Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Category:

Nutrition and Dietary Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Nutrition and Dietary Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Infection Control Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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.

Category:

Resident Rights Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Resident Assessment and Care Planning Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Quality of Life and Care Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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.

Category:

Pharmacy Service Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

Ensure medication error rates are not 5 percent or greater.

Category:

Pharmacy Service Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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.

Category:

Pharmacy Service Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Category:

Administration Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Category:

Nutrition and Dietary Deficiencies

Scope:

D

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Nutrition and Dietary Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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

Category:

Infection Control Deficiencies

Scope:

E

From Complaint:

N

Standard:

Y

Survey Date:

2018-08-02

Corrected:

2018-08-31

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