| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Environmental Deficiencies |
10/23/2003 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
10/23/2003 |
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 |
| Mistreatment Deficiencies |
10/23/2003 |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Widespread |
Potential for minimal harm |
| Pharmacy Service Deficiencies |
10/23/2003 |
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
10/23/2003 |
Make sure that residents who have not taken antipsychotic drugs are not given these drugs, unless they are used to treat a problem that is diagnosed and noted in the medical record. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
10/23/2003 |
Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
10/23/2003 |
Properly mark drugs and other similar products. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
10/23/2003 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
10/23/2003 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
10/23/2003 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
10/23/2003 |
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 |
10/23/2003 |
Keep assessments completed in the preceding 15 months in the resident's active record. |
Pattern |
Potential for minimal harm |
| Environmental Deficiencies |
12/11/2004 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
12/11/2004 |
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 |
| Pharmacy Service Deficiencies |
12/11/2004 |
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 |
12/11/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
12/11/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
12/11/2004 |
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 |
| Resident Assessment Deficiencies |
12/11/2004 |
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 |
12/11/2004 |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
12/11/2004 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
12/11/2004 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
06/15/2006 |
Give or get lab tests to meet the needs of residents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/15/2006 |
Provide needed housekeeping and maintenance. |
Pattern |
Potential for minimal harm |
| Nutrition and Dietary Deficiencies |
06/15/2006 |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Pattern |
Potential for minimal harm |
| Nutrition and Dietary Deficiencies |
06/15/2006 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/15/2006 |
Act when the pharmacist reports something unusual. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/15/2006 |
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 |
06/15/2006 |
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 |
06/15/2006 |
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 |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Corridor Walls and Doors Deficiencies |
10/30/2003 |
corridors that are separated from common areas by walls constructed to limit the passage of smoke. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
10/30/2003 |
properly installed electrical wiring and equipment. |
Pattern |
Potential for minimal harm |
| Furnishings and Decorations Deficiencies |
10/30/2003 |
exits that are free from obstructions and can be used at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
12/17/2004 |
corridors that are separated from common areas by walls constructed to limit the passage of smoke. |
Pattern |
Potential for minimal harm |
| Electrical Deficiencies |
12/17/2004 |
properly installed electrical wiring and equipment. |
Widespread |
Potential for minimal harm |
| Exits and Egress Deficiencies |
12/17/2004 |
proper exit design. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
12/17/2004 |
a fire alarm system that can be heard throughout the facility. |
Widespread |
Potential for minimal harm |
| Hazardous Area Deficiencies |
12/17/2004 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
12/17/2004 |
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
06/20/2006 |
corridor and hallway doors that block smoke. |
Pattern |
Potential for minimal harm |
| Exits and Egress Deficiencies |
06/20/2006 |
proper exit design. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
06/20/2006 |
an approved installation, maintenance and testing program for fire alarm systems. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
06/20/2006 |
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. |
Isolated |
Minimal harm or potential for actual harm |