Inspection Results » Our Lady of Peace Inc

Health Inspection on September 13, 2018 ^[1]

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

   • Provide and implement an infection prevention and control program. (Corrected 2018-10-28)

2. Pattern: No actual harm with potential for more than minimal 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 2018-10-28)

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

   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-10-28)
   • Assist a resident in gaining access to vision and hearing services. (Corrected 2018-10-28)
   • Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (Corrected 2018-10-28)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-10-28)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-10-28)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-10-28)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-10-28)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-10-28)
   • 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 2018-10-28)
   • Develop and implement policies and procedures for flu and pneumonia vaccinations. (Corrected 2018-10-28)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-10-28)