Inspection Results » Marlborough Hills Rehabilitation & Health Care Center

  1. Health Inspection on March 27, 2018 [1]

    1. Pattern: 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 2018-04-19)
    2. Isolated: Immediate jeopardy to the resident health or safety
      • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2018-04-18)
    3. Isolated: Actual harm that is not immediate jeopardy
      • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-04-18)
    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 2018-04-18)
      • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-04-18)
      • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-04-19)
      • Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. (Corrected 2018-04-19)
      • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2018-04-18)
      • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-04-18)
      • 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 2018-04-19)
      • Provide and implement an infection prevention and control program. (Corrected 2018-04-18)
      • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-04-18)
      • 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 2018-04-18)
    5. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy
      • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2018-04-18)
      • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-04-19)
      • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-04-18)
      • 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 2018-04-18)
      • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-04-18)
      • Ensure that residents are free from significant medication errors. (Corrected 2018-04-18)
      • Ensure each resident receives an accurate assessment. (Corrected 2018-04-19)
      • Assist a resident in gaining access to vision and hearing services. (Corrected 2018-04-18)
      • Provide activities to meet all resident's needs. (Corrected 2018-04-18)
      • Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. (Corrected 2018-04-19)
      • Keep residents' personal and medical records private and confidential. (Corrected 2018-04-19)
      • Respond appropriately to all alleged violations. (Corrected 2018-04-18)
      • 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 2018-04-18)
      • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2018-04-18)
      • Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Corrected 2018-04-16)
      • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-04-19)
      • 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 2018-04-18)
      • Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (Corrected 2018-04-18)

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