Inspection Results » Barrow Creek Health and Rehab

Health Inspection on August 31, 2018 ^[1]

1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-09-30)
   • Provide and implement an infection prevention and control program. (Corrected 2018-09-30)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-09-30)
   • Implement a program that monitors antibiotic use. (Corrected 2018-09-30)

2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • 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. (Corrected 2018-09-30)
   • 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. (Corrected 2018-09-30)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-09-30)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-09-30)
   • 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. (Corrected 2018-09-30)
   • Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. (Corrected 2018-09-30)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-09-30)
   • Ensure that residents are free from significant medication errors. (Corrected 2018-09-30)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-09-30)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-09-30)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2018-09-30)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-09-30)
   • Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (Corrected 2018-09-30)
   • Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. (Corrected 2018-09-30)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-09-30)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2018-09-30)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-09-30)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure each resident receives an accurate assessment. (Corrected 2018-09-30)
   • Assess the resident when there is a significant change in condition (Corrected 2018-09-30)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-09-30)
   • Develop and implement policies and procedures for flu and pneumonia vaccinations. (Corrected 2018-09-30)

4. Pattern: No actual harm with potential for minimal harm

   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-08-31)