Inspection Results » Las Flores Convalescent Hospital

  1. Health Inspection on October 30, 2018 [1]

    1. Widespread: Immediate jeopardy to the resident health or safety
      • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-12-12)
    2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-12-12)
      • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2019-01-11)
      • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-12-12)
      • Provide and implement an infection prevention and control program. (Corrected 2019-01-11)
      • Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. (Corrected 2018-12-12)
      • Ensure that residents are free from significant medication errors. (Corrected 2018-12-12)
      • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-12-12)
      • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-12-12)
      • 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. (Corrected 2018-12-12)
      • 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 2018-12-12)
      • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-12-12)
      • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-12-12)
      • 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 2018-12-12)
      • 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 2018-12-12)
      • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2019-01-11)
    3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Encode each residentÂ’s assessment data and transmit these data to the State within 7 days of assessment. (Corrected 2018-12-12)
      • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-12-12)
      • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-12-12)
      • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-12-12)
      • Ensure meals and snacks are served at times in accordance with residentÂ’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of schedu (Corrected 2018-12-12)
      • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2018-12-12)
      • Provide or get specialized rehabilitative services as required for a resident. (Corrected 2018-12-12)
      • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-12-12)
      • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2018-12-12)
      • 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 2018-12-12)
      • 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 2018-12-12)
      • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2019-01-11)
      • Assure that each residentÂ’s assessment is updated at least once every 3 months. (Corrected 2018-12-12)
      • Ensure each resident receives an accurate assessment. (Corrected 2018-12-12)
      • Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (Corrected 2018-12-12)

  2. Health Inspection on October 22, 2018 [1]

    1. Isolated: Actual harm that is not immediate jeopardy
      • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-11-21)

To be part of the Medicare and Medicaid programs, nursing homes have to meet certain requirements set by Congress. The Centers for Medicare and Medicaid Services (CMS) has entered into an agreement with state governments to do health inspections and fire safety inspections of these nursing homes and investigate complaints about nursing home care. [2]

About The Inspection Process


References

  1. http://www.medicare.gov/NursingHomeCompare/About/Health-Inspections.html
  2. http://www.medicare.gov/NursingHomeCompare/About/Inspection-Results.html