Inspection Results » Shepherd of the Valley Rehabilition and Wellness

Health Inspection on February 14, 2019 ^[1]

1. Isolated: Actual harm that is not immediate jeopardy

   • Provide enough food/fluids to maintain a resident's health. (Corrected 2019-03-19)

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

   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2019-03-19)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-03-19)

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

   • 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 2019-03-19)
   • Provide and implement an infection prevention and control program. (Corrected 2019-03-19)
   • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (Corrected 2019-03-19)
   • Implement a program that monitors antibiotic use. (Corrected 2019-03-19)

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

   • Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (Corrected 2019-03-19)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-03-19)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-03-19)
   • Assess the resident when there is a significant change in condition (Corrected 2019-03-19)
   • Provide activities to meet all resident's needs. (Corrected 2019-03-19)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-03-19)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-03-19)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2019-03-19)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2019-03-19)
   • PASARR screening for Mental disorders or Intellectual Disabilities (Corrected 2019-03-19)
   • Ensure each resident receives an accurate assessment. (Corrected 2019-03-19)