Inspection Results » Windsor Terrace Health Care

Health Inspection on April 26, 2018 ^[1]

1. 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 2018-05-25)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-05-25)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-05-25)
   • 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 2018-05-25)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-05-25)
   • Ensure services provided by the nursing facility meet professional standards of quality. (Corrected 2018-05-25)
   • 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 2018-05-25)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-05-25)
   • Provide and implement an infection prevention and control program. (Corrected 2018-05-25)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-05-25)

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

   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-05-25)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-05-25)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-05-25)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-05-25)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-05-25)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-05-25)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-05-25)

3. Pattern: No actual harm with potential for minimal harm

   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-05-25)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-05-25)
   • Encode each residentÂ’s assessment data and transmit these data to the State within 7 days of assessment. (Corrected 2018-05-25)