Inspection Results » Santa Teresita Manor

Health Inspection on August 10, 2018 ^[1]

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

   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-09-10)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-09-10)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-09-10)
   • Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (Corrected 2018-09-10)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-09-10)

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

   • Implement a program that monitors antibiotic use. (Corrected 2018-09-10)
   • 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 ne (Corrected 2018-09-10)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-09-10)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-09-10)
   • 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 2018-09-10)
   • Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. (Corrected 2018-09-10)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-09-10)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-09-10)
   • Provide and implement an infection prevention and control program. (Corrected 2018-09-10)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-09-10)

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

   • Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. (Corrected 2018-09-10)