| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
09/12/2003 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
09/12/2003 |
Keep safe, clean and homelike surroundings. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
09/12/2003 |
Make sure that residents are well nourished. |
Widespread |
Potential for minimal harm |
| Nutrition and Dietary Deficiencies |
09/12/2003 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
09/12/2003 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
09/12/2003 |
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 |
09/12/2003 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
09/12/2003 |
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 |
09/12/2003 |
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 |
09/12/2003 |
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 |
09/12/2003 |
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 |
09/12/2003 |
Check and update (if needed) each resident's assessment every 3 months. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
09/12/2003 |
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 Assessment Deficiencies |
09/12/2003 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
09/12/2003 |
Try to resolve each resident's complaints quickly. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
09/12/2003 |
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 |
09/12/2003 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
09/30/2004 |
Hire a qualified social worker; or in homes with more than 120 beds, hire a qualified full-time social worker. |
Widespread |
Potential for minimal harm |
| Administration Deficiencies |
09/30/2004 |
Give lab tests only when the attending doctor ordered them. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
09/30/2004 |
Keep safe, clean and homelike surroundings. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
09/30/2004 |
Get rid of garbage properly. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
09/30/2004 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
09/30/2004 |
Keep all essential equipment working safely. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
09/30/2004 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
09/30/2004 |
Make sure there is a program to prevent/deal with mice, insects, or other pests. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
09/30/2004 |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
09/30/2004 |
Keep drugs and other similar products locked safely and properly stored. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
09/30/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
09/30/2004 |
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 |
09/30/2004 |
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 |
09/30/2004 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
09/30/2004 |
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 |
09/30/2004 |
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 Rights Deficiencies |
09/30/2004 |
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
09/30/2004 |
Let residents complain without being treated differently or badly. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
04/06/2006 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/06/2006 |
Make sure there is a program to prevent/deal with mice, insects, or other pests. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
04/06/2006 |
Provide food in a way that meets a resident's needs. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
04/06/2006 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
04/06/2006 |
Use the services of a licensed pharmacist. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
04/06/2006 |
Keep drugs and other similar products locked safely and properly stored. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/06/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/06/2006 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
04/06/2006 |
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 |
04/06/2006 |
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 |
04/06/2006 |
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 Assessment Deficiencies |
04/06/2006 |
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 |
04/06/2006 |
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 |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Emergency Plans and Fire Drills Deficiencies |
09/26/2003 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Potential for minimal harm |
| Automatic Sprinkler Systems Deficiencies |
09/30/2004 |
portable fire extinguishers. |
Pattern |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
09/30/2004 |
proper exit design. |
Isolated |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
09/30/2004 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Isolated |
Minimal harm or potential for actual harm |
| Building Contruction Deficiencies |
04/13/2006 |
fire-resistant Interior walls. |
Isolated |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
04/13/2006 |
properly protected cooking facilities. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
04/13/2006 |
corridor and hallway doors that block smoke. |
Pattern |
Potential for minimal harm |
| Electrical Deficiencies |
04/13/2006 |
properly installed electrical wiring and equipment. |
Isolated |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
04/13/2006 |
record of quarterly fire drills for each shift under varying conditions. |
Pattern |
Potential for minimal harm |
| Exits and Egress Deficiencies |
04/13/2006 |
corridors or aisles that are unobstructed and are at least 8 feet in width. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
04/13/2006 |
an approved installation, maintenance and testing program for fire alarm systems. |
Isolated |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
04/13/2006 |
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 |
04/13/2006 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Isolated |
Minimal harm or potential for actual harm |