| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
11/06/2003 |
Get services outside the nursing home that meet professional standards. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
11/06/2003 |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/06/2003 |
Provide food in a way that meets a resident's needs. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/06/2003 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
11/06/2003 |
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 |
11/06/2003 |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/06/2003 |
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 |
11/06/2003 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/06/2003 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/06/2003 |
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 |
11/06/2003 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
11/06/2003 |
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 |
11/06/2003 |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
11/06/2003 |
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
11/06/2003 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Isolated |
Actual harm |
| Resident Assessment Deficiencies |
11/06/2003 |
Do a new assessment after any major change in a resident's physical or mental health. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
11/06/2003 |
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 |
11/06/2003 |
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 |
11/06/2003 |
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
11/06/2003 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/13/2005 |
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 |
01/13/2005 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Widespread |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/13/2005 |
Give or get lab tests to meet the needs of residents. |
Widespread |
Immediate jeopardy to resident health or safety |
| Administration Deficiencies |
01/13/2005 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/13/2005 |
Set up or keep a group of people to review and ensure quality. |
Widespread |
Actual harm |
| Environmental Deficiencies |
01/13/2005 |
Keep safe, clean and homelike surroundings. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
01/13/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/13/2005 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/13/2005 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/13/2005 |
Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/13/2005 |
Make sure that a working call system is available in each resident's room or bathroom and bathing area. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
01/13/2005 |
Protect residents from mistreatment, neglect, and/or theft of personal property. |
Isolated |
Actual harm |
| Mistreatment Deficiencies |
01/13/2005 |
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 |
01/13/2005 |
Offer other nutritional food to each resident who will not eat the food served. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
01/13/2005 |
Make sure that the attending doctor orders special diets. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
01/13/2005 |
1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
01/13/2005 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
01/13/2005 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
01/13/2005 |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
01/13/2005 |
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. |
Widespread |
Immediate jeopardy to resident health or safety |
| Pharmacy Service Deficiencies |
01/13/2005 |
Use the services of a licensed pharmacist. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/13/2005 |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
01/13/2005 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/13/2005 |
Give professional services that follow each resident's written care plan. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/13/2005 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Pattern |
Actual harm |
| Quality Care Deficiencies |
01/13/2005 |
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/13/2005 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
01/13/2005 |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
01/13/2005 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
01/13/2005 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
01/13/2005 |
Let the resident or the resident's representative look at all records. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
01/13/2005 |
Keep each resident's personal and medical records private and confidential. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
01/13/2005 |
Try to resolve each resident's complaints quickly. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
01/13/2005 |
Provide written records when a resident is transferred or discharged. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
01/13/2005 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
01/13/2005 |
Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
01/13/2005 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/13/2006 |
Get rid of garbage properly. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/13/2006 |
Make sure that residents are well nourished. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/13/2006 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
07/13/2006 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/13/2006 |
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 |
07/13/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/13/2006 |
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 |
07/13/2006 |
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 |
07/13/2006 |
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 |
07/13/2006 |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
07/13/2006 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/13/2006 |
Quickly give a resident's personal money to the heads of his or her estate after the resident's death. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Corridor Walls and Doors Deficiencies |
11/14/2003 |
corridors that are separated from common areas by walls constructed to limit the passage of smoke. |
Pattern |
Potential for minimal harm |
| Electrical Deficiencies |
07/18/2006 |
properly installed electrical wiring and equipment. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
07/18/2006 |
an approved installation, maintenance and testing program for fire alarm systems. |
Isolated |
Minimal harm or potential for actual harm |
| Smoking Regulations Deficiencies |
07/18/2006 |
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. |
Isolated |
Minimal harm or potential for actual harm |