Inspection Results » Seton Medical Center Distinct Part Skilled Nursing Facility

Health Inspection on September 13, 2018 ^[1]

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

   • 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. (Corrected 2018-11-30)
   • 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 2018-11-30)

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

   • Develop and implement policies and procedures for flu and pneumonia vaccinations. (Corrected 2018-11-30)
   • Hire a qualified full-time social worker in a facility with more than 120 beds. (Corrected 2018-11-30)
   • Provide medically-related social services to help each resident achieve the highest possible quality of life. (Corrected 2018-11-30)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-11-30)

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

   • Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (Corrected 2018-11-30)
   • Provide and implement an infection prevention and control program. (Corrected 2018-11-30)
   • Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (Corrected 2018-11-30)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-11-30)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2018-11-30)
   • 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 2018-11-30)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-11-30)
   • 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. (Corrected 2018-11-30)
   • Respond appropriately to all alleged violations. (Corrected 2018-11-30)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-11-30)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-11-30)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2018-11-30)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-11-30)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-11-30)