| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
06/08/2003 |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Widespread |
Immediate jeopardy to resident health or safety |
| Administration Deficiencies |
06/08/2003 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
06/08/2003 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
06/08/2003 |
Train all employees on what to do in an emergency. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/08/2003 |
Keep safe, clean and homelike surroundings. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/08/2003 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/08/2003 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
06/08/2003 |
1) Hire only people who have 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 harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
06/08/2003 |
Make sure that residents are well nourished. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
06/08/2003 |
Offer other nutritional food to each resident who will not eat the food served. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/08/2003 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/08/2003 |
Make sure that residents are safe from serious medication errors. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/08/2003 |
Keep drugs and other similar products locked safely and properly stored. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Provide activities to meet the needs of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Give each resident care and services to get or keep the highest quality of life possible. |
Widespread |
Immediate jeopardy to resident health or safety |
| Quality Care Deficiencies |
06/08/2003 |
Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/08/2003 |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/08/2003 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Widespread |
Immediate jeopardy to resident health or safety |
| Resident Assessment Deficiencies |
06/08/2003 |
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/08/2003 |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Widespread |
Immediate jeopardy to resident health or safety |
| Resident Assessment Deficiencies |
06/08/2003 |
1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/08/2003 |
Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/08/2003 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
07/30/2004 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/30/2004 |
Have a program to keep infection from spreading. |
Widespread |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
07/30/2004 |
1) Hire only people who have 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 harm or potential for actual harm |
| Quality Care Deficiencies |
07/30/2004 |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/30/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/30/2004 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/30/2004 |
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/30/2004 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Immediate jeopardy to resident health or safety |
| Resident Rights Deficiencies |
07/30/2004 |
Protect the resident from a transfer or discharge that is not wanted or needed. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/30/2004 |
Provide written records when a resident is transferred or discharged. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/30/2004 |
Provide enough notice before discharging or transferring a resident. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/30/2004 |
Help and prepare each resident for a safe and easy discharge and transfer from the nursing home. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/30/2004 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
04/28/2006 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/28/2006 |
Get rid of garbage properly. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/28/2006 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/28/2006 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/28/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/28/2006 |
Give professional services that follow each resident's written care plan. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/28/2006 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| Resident Assessment Deficiencies |
04/28/2006 |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
04/28/2006 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
04/28/2006 |
Try to resolve each resident's complaints quickly. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
04/28/2006 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
04/28/2006 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Automatic Sprinkler Systems Deficiencies |
06/11/2003 |
an approved automatic sprinkler system connected to the fire alarm system. |
Pattern |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
06/11/2003 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Potential for minimal harm |
| Exits and Egress Deficiencies |
06/11/2003 |
exits that are accessible at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Miscellaneous Deficiencies |
06/11/2003 |
fire safety features required by current fire safety codes. |
Pattern |
Potential for minimal harm |
| Automatic Sprinkler Systems Deficiencies |
08/04/2004 |
portable fire extinguishers. |
Widespread |
Potential for minimal harm |
| Building Service Equipment Deficiencies |
08/04/2004 |
properly protected cooking facilities. |
Pattern |
Potential for minimal harm |
| Building Service Equipment Deficiencies |
05/03/2006 |
properly protected cooking facilities. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
05/03/2006 |
properly installed electrical wiring and equipment. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
05/03/2006 |
an approved installation, maintenance and testing program for fire alarm systems. |
Pattern |
Potential for minimal harm |
| Smoke Compartmentation and Control Deficiencies |
05/03/2006 |
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. |
Pattern |
Minimal harm or potential for actual harm |