AHMC SETON MEDICAL CENTER, DALY CITY, CA — Violations & Inspection Reports

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

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.

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

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 necessary and PRN use is limited.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

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.

Ensure each resident receives an accurate assessment.

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.

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.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

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.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Keep all essential equipment working safely.

Put firmly secured handrails on each side of hallways.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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.

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.

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Make sure that a working call system is available in each resident's bathroom and bathing area.

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Provide and implement an infection prevention and control program.

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Keep all essential equipment working safely.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Ensure medication error rates are not 5 percent or greater.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Ensure services provided by the nursing facility meet professional standards of quality.

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Ensure each resident receives an accurate assessment.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Reasonably accommodate the needs and preferences of each resident.

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Ensure staff are vaccinated for COVID-19

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.