Inspection Results » Mission San Miguel Nursing and Rehab Center

  1. Health Inspection on January 29, 2019 [1]

    1. Isolated: Immediate jeopardy to the resident health or safety
      • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-03-20)
    2. Isolated: Actual harm that is not immediate jeopardy
      • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2019-03-06)
    3. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Ensure the activities program is directed by a qualified professional. (Corrected 2019-03-06)
      • 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 2019-03-20)
      • Have a plan that describes the process for conducting QAPI and QAA activities. (Corrected 2019-03-20)
      • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2019-03-20)
      • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2019-03-20)
      • Make sure that a working call system is available in each resident's bathroom and bathing area. (Corrected 2019-03-20)
    4. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2019-03-20)
      • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-03-20)
      • Provide enough food/fluids to maintain a resident's health. (Corrected 2019-03-20)
      • 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 2019-03-20)
      • Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. (Corrected 2019-03-20)
      • Provide activities to meet all resident's needs. (Corrected 2019-03-20)
      • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-03-20)
      • Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. (Corrected 2019-03-20)
      • Implement a program that monitors antibiotic use. (Corrected 2019-03-20)
      • Provide and implement an infection prevention and control program. (Corrected 2019-03-20)
    5. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2019-03-20)
      • 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 2019-03-20)
      • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2019-03-20)
      • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2019-03-20)
      • Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. (Corrected 2019-03-20)
      • Provide care by qualified persons according to each resident's written plan of care. (Corrected 2019-03-20)
    6. Widespread: No actual harm with potential for minimal harm
      • Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. (Corrected 2019-03-06)
      • Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. (Corrected 2019-03-20)

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