Inspection Results » Enterprise Estates Nursing Center

  1. Health Inspection on April 23, 2019 [1]

    1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. (Corrected N/A)
      • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected N/A)
      • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected N/A)
      • Provide and implement an infection prevention and control program. (Corrected N/A)
      • Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. (Corrected N/A)
      • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected N/A)
      • Assess the resident when there is a significant change in condition (Corrected N/A)
      • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected N/A)
      • Assure that each residentÂ’s assessment is updated at least once every 3 months. (Corrected N/A)
    2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • 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 N/A)
      • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected N/A)
      • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected N/A)
    3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected N/A)
      • Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. (Corrected N/A)
      • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected N/A)
      • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected N/A)
      • Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install (Corrected N/A)
      • Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. (Corrected N/A)
      • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected N/A)
      • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected N/A)
      • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected N/A)
      • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected N/A)
      • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected N/A)
      • 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 N/A)
      • Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Corrected N/A)

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