DEER PARK HEALTH & REHABILITATION

Nursing Home Inspector

306 DEER PARK ROAD
NEBO, NC 28761
Mc Dowell County
Phone: 828-652-3032
Provider Number: 345233
Last Inspection: 03/02/2017

About the Nursing Home

Number of Beds: 140
Number of Residents: 87
Beds Available: 53
Percent Occupancy: 62%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

44

Facility
22

County
14

NC
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

44

2017
23

2016
13

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/2/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 4/21/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 4/21/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 4/21/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 4/21/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 5/15/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 5/15/2017
 
Failed To: Provide residents with private access to a telephone. Isolated : Minimal 3 4/21/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 4/21/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 4/21/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 4/21/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 4/21/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 4/21/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 4/21/2017
 

3/17/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 4/8/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 4/8/2016
 
Failed To: Maintain 15 months of resident assessments in the resident's active clinical record. Widespread : Minimal 5 4/8/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 4/8/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 4/8/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 4/8/2016
 

6/5/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 6/28/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 6/28/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 6/28/2015
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 6/28/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

11/22/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 12/16/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 12/16/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 12/16/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 12/16/2016
 

10/6/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 11/7/2016
 
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 11/7/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 12/16/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 11/7/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 11/7/2016
 
Failed To: Provide or obtain laboratory services only when ordered by the attending physician. Isolated : Minimal 3 11/7/2016
 
Failed To: Quickly tell the resident's doctor the results of laboratory tests. Isolated : Minimal 3 11/7/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 11/7/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 12/16/2016
 

1/22/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 2/18/2015
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 2/18/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NC State Avg
Number of Residents 87 93.00 84.96
Registered Nurses 0.76 0.92 0.72
Licensed Practical / Vocational Nurses 0.96 0.75 0.87
Certified Nursing Assistants 2.05 2.22 2.33
Total Staff Hours 3.77 3.89 3.91

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NC State Avg%
of high risk long-stay residents with pressure ulcers 8 7 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 99 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 88 94 93
of long-stay residents experiencing one or more falls with major injury 2 5 3
of long-stay residents who have depressive symptoms 0 0 2
of long-stay residents who lose too much weight 17 12 8
of long-stay residents who received an antianxiety or hypnotic medication 53 36 29
of long-stay residents who received an antipsychotic medication 19 12 13
of long-stay residents who self-report moderate to severe pain 11 10 6
of long-stay residents who were physically restrained 4 2 0
of long-stay residents whose ability to move independently worsened 21 20 23
of long-stay residents whose need for help with daily activities has increased 18 16 18
of long-stay residents with a catheter inserted and left in their bladder 4 2 1
of long-stay residents with a urinary tract infection 1 3 4
of low risk long-stay residents who lose control of their bowels or bladder 56 55 55
of short-stay residents assessed and appropriately given the pneumococcal vaccine 88 93 83
of short-stay residents who had an outpatient emergency department visit 22 18 13
of short-stay residents who made improvements in function 70 73 64
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 22 24 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 68 82 81
of short-stay residents who were rehospitalized after a nursing home admission 21 20 20
of short-stay residents who were successfully discharged to the community 47 56 55
of short-stay residents with pressure ulcers that are new or worsened 1 1 0