Inspection Results » Loch Raven Center

Health Inspection on January 10, 2019 ^[1]

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

   • Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. (Corrected 2019-03-01)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-03-01)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2019-03-01)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-03-01)
   • 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 2019-03-01)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2019-03-01)
   • 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 2019-03-01)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2019-03-01)

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 2019-03-01)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2019-03-01)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2019-03-01)
   • Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. (Corrected 2019-03-01)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-03-01)
   • Ensure that residents are free from significant medication errors. (Corrected 2019-03-01)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-03-01)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-03-01)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2019-03-01)
   • 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 2019-03-01)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-03-01)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-03-01)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2019-03-01)
   • Ensure each resident receives an accurate assessment. (Corrected 2019-03-01)
   • Provide and implement an infection prevention and control program. (Corrected 2019-03-01)
   • 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 2019-03-01)

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 2019-03-01)
   • Allow resident to participate in the development and implementation of his or her person-centered plan of care. (Corrected 2019-03-01)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2019-03-01)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2019-03-01)
   • 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 2019-03-01)
   • Provide activities to meet all resident's needs. (Corrected 2019-03-01)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2019-03-01)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2019-03-01)
   • Prepare residents for a safe transfer or discharge from the nursing home. (Corrected 2019-03-01)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2019-03-01)
   • Assess the resident when there is a significant change in condition (Corrected 2019-03-01)
   • 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 2019-03-01)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2019-03-01)
   • Assist a resident in gaining access to vision and hearing services. (Corrected 2019-03-01)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2019-03-01)
   • Provide timely, quality laboratory services/tests to meet the needs of residents. (Corrected 2019-03-01)

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

   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2019-03-01)
   • Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. (Corrected 2019-03-01)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2019-03-01)