Inspection Results » Creswell Health and Rehabilitation Center

Health Inspection on January 31, 2018 ^[1]

1. Widespread: Immediate jeopardy to the resident health or safety

   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2018-03-22)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-03-22)

2. Pattern: Immediate jeopardy to the resident health or safety

   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-05-17)
   • Provide timely, quality laboratory services/tests to meet the needs of residents. (Corrected 2018-03-22)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-03-22)

3. Isolated: Immediate jeopardy to the resident health or safety

   • Ensure that residents are free from significant medication errors. (Corrected 2018-03-22)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-05-17)

4. Isolated: Actual harm that is not immediate jeopardy

   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-03-22)

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

   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-03-22)
   • Make sure that a working call system is available in each resident's bathroom and bathing area. (Corrected 2018-03-22)
   • Observe each nurse aide's job performance and give regular training. (Corrected 2018-03-22)

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

   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-03-22)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-03-22)
   • 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 2018-03-22)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-05-17)
   • Develop and implement policies and procedures for flu and pneumonia vaccinations. (Corrected 2018-03-22)
   • 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 2018-03-22)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-05-17)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-03-22)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-05-17)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2018-03-22)

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

   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2018-05-17)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-03-22)
   • 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 2018-03-22)
   • Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. (Corrected 2018-03-22)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-03-22)
   • Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. (Corrected 2018-03-22)
   • Implement a program that monitors antibiotic use. (Corrected 2018-03-22)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-03-22)
   • 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 2018-03-22)
   • Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. (Corrected 2018-03-22)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-03-22)
   • Plan the resident's discharge to meet the resident's goals and needs. (Corrected 2018-03-22)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-03-22)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-03-22)
   • Provide and implement an infection prevention and control program. (Corrected 2018-03-22)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-03-22)
   • 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 2018-03-22)