Inspection Results » Sunshine Haven at Lordsburg

Health Inspection on September 27, 2018 ^[1]

1. Pattern: Actual harm that is not immediate jeopardy

   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-10-26)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-10-26)

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

   • 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 2018-10-26)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-10-26)
   • Provide and implement an infection prevention and control program. (Corrected 2018-10-26)
   • Implement a program that monitors antibiotic use. (Corrected 2018-10-26)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-10-26)

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

   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-10-26)
   • 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 2018-10-26)
   • 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 2018-10-26)
   • Provide or obtain dental services for each resident. (Corrected 2018-10-26)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-10-26)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-10-26)
   • Ensure that the resident and his/her doctor meet face-to-face at all required visits. (Corrected 2018-10-26)

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

   • Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Corrected 2018-10-26)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-10-26)
   • Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (Corrected 2018-10-26)
   • Assist a resident in gaining access to vision and hearing services. (Corrected 2018-10-26)
   • Assess the resident when there is a significant change in condition (Corrected 2018-10-26)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-10-26)

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

   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-10-26)