TOP 10 DEFICIENCIES WRITTEN BETWEEN

12/01/2011 AND 06/01/2012

# 1: F 282The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident’s written plan of care.The facility failed to follow the care plan or the facility failed to follow MDorder

# 2: F 279 Develop Comprehensive Care Plan

The facility failed to develop a care plan for conditions/risks that were present during comprehensive assessment window of opportunity

#3: F 280 Right to Participate in Care Planning / Comprehensive Care Plan

The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment.

F 280A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment

# 4: F 272 Comprehensive Assessments

The facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

#5: F 323 Free of Accident Hazards / Supervision to Prevent AccidentsThe facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

# 6: F 441 Infection ControlThe facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

F 441 Continued

Infection Control Program:1) Investigates, controls, and prevents infections in the facility;2) Decides what procedures, such as isolation, should be applied to resident and3) Maintains record of incidents and corrective actions related to infections.

F 441 Continued(b) Prevent Spread of Infection

(1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident.

(2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.

(3) The facility must require staff to wash their hands after each direct resident contact for which hand washing

is indicated by accepted professional practice.

F 441 Continued(c) Linens

Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

#7 F 371: Food Procurement/ Sanitary Conditions

The facility must -(1) Procure food from sources

approved or considered satisfactory by Federal, State or local authorities; and

(2) Store, prepare, distribute and serve food under sanitary conditions

#8 F 253: Housekeeping and Maintenance Services

Necessary to maintain a sanitary, orderly, and comfortable interior

Responsible to provide effective housekeeping and maintenance services

Ex.: dirty resident care equipment

# 9 F 329: Free from Unnecessary Drugs

Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above.

F 329 continuedBased on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

# 10 F 281: Services Provided Meet Professional Standards

Assure that services being provided meet professional Standards of quality and are provided by appropriate qualified persons.

Professional standards of Quality means services are provided according to accepted standards of practice.

Standards may apply to care provided by particular discipline or in a specific clinical situation

# 10 F 514: Clinical RecordsThe facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized.

The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.