| Percent of High Risk Long Term Nursing Home Residents Who Have Pressure Sores: 14% |
| Percent of Long Term Nursing Home Residents Given Influenza Vaccination During the Flu Season: 89% |
| Percent of Long Term Nursing Home Residents Who are More Depressed or Anxious: 10% |
| Percent of Long Term Nursing Home Residents Who Have Moderate to Severe Pain: 2% |
| Percent of Long Term Nursing Home Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 6% |
| Percent of Long Term Nursing Home Residents Who Lose Too Much Weight: 12% |
| Percent of Long Term Nursing Home Residents Who Spend Most of Their Time in Bed or in a Chair: 4% |
| Percent of Long Term Nursing Home Residents Who Were Assessed and Given Pneumococcal Vaccination: 15% |
| Percent of Long Term Nursing Home Residents Who Were Physically Restrained: 1% |
| Percent of Long Term Nursing Home Residents Whose Ability to Move About in and Around Their Room Got Worse: 10% |
| Percent of Long Term Nursing Home Residents Whose Need for Help With Daily Activities Has Increased: 9% |
| Percent of Long Term Nursing Home Residents With a Urinary Tract Infection: 17% |
| Percent of Low-Risk Long Term Nursing Home Residents Who Have Pressure Sores: 1% |
| Percent of Low-Risk Long Term Nursing Home Residents Who Lose Control of Their Bowels or Bladder: 62% |
| Percent of Short Term Nursing Home Residents Given Influenza Vaccination During the Flu Season: 77% |
| Percent of Short Term Nursing Home Residents Who Had Moderate to Severe Pain: 12% |
| Percent of Short Term Nursing Home Residents Who Were Assessed and Given Pneumococcal Vaccination: 41% |
| Percent of Short Term Nursing Home Residents With Delirium: 0% |
| Percent of Short Term Nursing Home Residents With Pressure Sores: 17% |
Nursing Home Violations by Village At Cook Springs Skilled Nursing Facility
|
| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
05/27/2004 |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Isolated |
Immediate jeopardy to resident health or safety |
| Environmental Deficiencies |
05/27/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Immediate jeopardy to resident health or safety |
| Quality Care Deficiencies |
05/27/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/27/2004 |
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/27/2004 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
05/27/2004 |
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 |
05/27/2004 |
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 |
08/25/2005 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/25/2005 |
Provide needed housekeeping and maintenance. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/25/2005 |
Make sure there is a program to prevent/deal with mice, insects, or other pests. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
08/25/2005 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
08/25/2005 |
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 Rights Deficiencies |
08/25/2005 |
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 |
08/25/2005 |
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
08/25/2005 |
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 |
| Resident Rights Deficiencies |
08/25/2005 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
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 |
06/04/2004 |
corridor and hallway doors that block smoke. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
06/04/2004 |
weekly inspections and monthly testing of generators. |
Widespread |
Potential for minimal harm |
| Electrical Deficiencies |
06/04/2004 |
properly installed electrical wiring and equipment. |
Widespread |
Potential for minimal harm |
| Exits and Egress Deficiencies |
06/04/2004 |
exits that are accessible at all times. |
Pattern |
Potential for minimal harm |
| Exits and Egress Deficiencies |
06/04/2004 |
proper exit design. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
06/04/2004 |
a fire alarm system that can be heard throughout the facility. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
06/04/2004 |
an approved installation, maintenance and testing program for fire alarm systems. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
06/04/2004 |
properly maintained smoke detectors. |
Widespread |
Potential for minimal harm |
| Smoke Compartmentation and Control Deficiencies |
06/04/2004 |
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 |
| Smoke Compartmentation and Control Deficiencies |
06/04/2004 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Pattern |
Potential for minimal harm |
| Smoke Compartmentation and Control Deficiencies |
06/04/2004 |
proper construction of ducts through walls designed to prevent smoke passage. |
Pattern |
Potential for minimal harm |
| Automatic Sprinkler Systems Deficiencies |
09/02/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Isolated |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
09/02/2005 |
automatic sprinkler systems that have been maintained in working order. |
Isolated |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
09/02/2005 |
record of quarterly fire drills for each shift under varying conditions. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
09/02/2005 |
an approved installation, maintenance and testing program for fire alarm systems. |
Widespread |
Minimal harm or potential for actual harm |