Inspection Results » Country Villa Plaza Convalescent Center

Health Inspection on March 11, 2019 ^[1]

1. Widespread: No actual harm with potential for more than minimal 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 2019-05-13)

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

   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-04-26)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-04-26)
   • Provide activities to meet all resident's needs. (Corrected 2019-04-26)
   • Implement a program that monitors antibiotic use. (Corrected 2019-04-26)

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

   • 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 2019-04-26)
   • Have a plan that describes the process for conducting QAPI and QAA activities. (Corrected 2019-04-26)
   • Provide timely, quality laboratory services/tests to meet the needs of residents. (Corrected 2019-04-26)
   • 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 2019-05-13)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-04-26)
   • Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (Corrected 2019-04-26)
   • 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 2019-04-26)
   • 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 2019-04-26)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2019-04-26)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-04-26)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2019-04-26)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2019-04-26)
   • Provide and implement an infection prevention and control program. (Corrected 2019-04-26)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2019-04-26)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2019-04-26)
   • Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (Corrected 2019-04-26)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2019-05-13)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-04-26)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2019-04-26)

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

   • Dispose of garbage and refuse properly. (Corrected 2019-04-26)
   • Ensure each resident receives an accurate assessment. (Corrected 2019-04-26)