Inspection Results » Grove of Berwyn, The

Health Inspection on March 22, 2018 ^[1]

1. Pattern: Actual harm that is not immediate jeopardy

   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-04-20)

2. Isolated: Actual harm that is not immediate jeopardy

   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-04-20)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-04-20)

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

   • Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. (Corrected 2018-04-20)
   • Have a plan that describes the process for conducting QAPI and QAA activities. (Corrected 2018-04-20)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-04-20)
   • Have the Quality Assessment and Assurance group have the required members and meet at least quarterly (Corrected 2018-04-20)

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

   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-04-20)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-04-20)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-04-20)

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

   • Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. (Corrected 2018-04-20)