Inspection Results » Willow Glen Health and Rehab

Health Inspection on January 24, 2019 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • 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 2019-02-27)

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

   • 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 2019-02-27)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-02-27)
   • Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Corrected 2019-02-27)
   • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (Corrected 2019-02-27)
   • Provide and implement an infection prevention and control program. (Corrected 2019-02-27)

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

   • Ensure that residents are free from significant medication errors. (Corrected 2019-02-27)
   • 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 2019-02-27)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2019-02-27)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2019-02-27)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-02-27)