Inspection Results » Talbot Center for Rehab & Healthcare

Health Inspection on February 9, 2018 ^[1]

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

   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-03-26)
   • Ensure that residents are fully informed and understand their health status, care and treatments. (Corrected 2018-03-26)
   • Provide and implement an infection prevention and control program. (Corrected 2018-03-26)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-03-26)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2018-03-26)
   • Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. (Corrected 2018-03-26)
   • 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 2018-03-26)
   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2018-03-26)
   • Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. (Corrected 2018-03-26)
   • 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 2018-03-26)
   • Provide for the safe, appropriate administration of IV fluids for a resident when needed. (Corrected 2018-03-26)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-03-26)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-03-26)
   • 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 2018-03-26)
   • Develop and implement policies and procedures for flu and pneumonia vaccinations. (Corrected 2018-03-26)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-03-26)
   • 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 2018-03-26)
   • 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 2018-03-26)
   • 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 2018-03-26)
   • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2018-03-26)
   • Assure that each residentÂ’s assessment is updated at least once every 3 months. (Corrected 2018-03-26)
   • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2018-03-26)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-03-26)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-03-26)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-03-26)
   • 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 2018-03-26)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-03-26)
   • 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 2018-03-26)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2018-03-26)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-03-26)
   • 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 2018-03-26)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2018-03-26)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-03-26)
   • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (Corrected 2018-03-26)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2018-03-26)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2018-03-26)
   • Provide or obtain dental services for each resident. (Corrected 2018-03-26)
   • 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 2018-03-26)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-03-26)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-03-26)
   • Observe each nurse aide's job performance and give regular training. (Corrected 2018-03-26)
   • Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. (Corrected 2018-03-26)
   • Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. (Corrected 2018-03-26)

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

   • Assist a resident in gaining access to vision and hearing services. (Corrected 2018-03-26)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-03-26)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-03-26)
   • Respond appropriately to all alleged violations. (Corrected 2018-03-26)
   • Encode each residentÂ’s assessment data and transmit these data to the State within 7 days of assessment. (Corrected 2018-03-26)
   • Keep residents' personal and medical records private and confidential. (Corrected 2018-03-26)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-03-26)
   • Provide timely, quality laboratory services/tests to meet the needs of residents. (Corrected 2018-03-26)
   • Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. (Corrected 2018-03-26)