| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
03/18/2004 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/18/2004 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/18/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/18/2004 |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/18/2004 |
Make sure that staff members wash their hands when needed. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/18/2004 |
Make sure that a working call system is available in each resident's room or bathroom and bathing area. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
03/18/2004 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
03/18/2004 |
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 |
| Quality Care Deficiencies |
03/18/2004 |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/18/2004 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/18/2004 |
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/18/2004 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/18/2004 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/18/2004 |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/18/2004 |
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 |
03/18/2004 |
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 |
03/18/2004 |
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 |
03/18/2004 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/18/2004 |
Let residents give themselves their drugs if they are able. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/18/2004 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/09/2005 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/09/2005 |
Set up or keep a group of people to review and ensure quality. |
Pattern |
Actual harm |
| Environmental Deficiencies |
03/09/2005 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/09/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/09/2005 |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/09/2005 |
Make sure that a working call system is available in each resident's room or bathroom and bathing area. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
03/09/2005 |
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 |
03/09/2005 |
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 |
Potential for minimal harm |
| Nutrition and Dietary Deficiencies |
03/09/2005 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Potential for minimal harm |
| Quality Care Deficiencies |
03/09/2005 |
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 |
03/09/2005 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/09/2005 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/09/2005 |
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 |
03/09/2005 |
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 |
03/09/2005 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Pattern |
Actual harm |
| Quality Care Deficiencies |
03/09/2005 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/09/2005 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/09/2005 |
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 |
03/09/2005 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/09/2005 |
Assess the resident when the resident enters the nursing home, in a timely manner. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/09/2005 |
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 |
03/09/2005 |
Check and update (if needed) each resident's assessment every 3 months. |
Pattern |
Potential for minimal harm |
| Resident Assessment Deficiencies |
03/09/2005 |
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 Assessment Deficiencies |
03/09/2005 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/09/2005 |
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 |
03/09/2005 |
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 |
| Administration Deficiencies |
06/01/2006 |
Hire a qualified social worker; or in homes with more than 120 beds, hire a qualified full-time social worker. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/01/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/01/2006 |
Keep all essential equipment working safely. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/01/2006 |
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 |
06/01/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/01/2006 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
06/01/2006 |
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 |
06/01/2006 |
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 |
06/01/2006 |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
06/01/2006 |
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 |
06/01/2006 |
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 Assessment Deficiencies |
06/01/2006 |
Screen residents when they are first admitted to send them to an area with special care for people with developmental disabilities or mental illness, if needed. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/01/2006 |
Give the resident's legal representative the same rights as the resident. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/01/2006 |
Keep each resident's personal and medical records private and confidential. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/01/2006 |
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. |
Pattern |
Potential for minimal harm |
| Resident Rights Deficiencies |
06/01/2006 |
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 |
04/01/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Isolated |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
04/01/2005 |
automatic sprinkler systems that have been maintained in working order. |
Isolated |
Minimal harm or potential for actual harm |
| Building Contruction Deficiencies |
04/01/2005 |
approved construction type or materials. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
04/01/2005 |
corridor and hallway doors that block smoke. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
04/01/2005 |
properly installed electrical wiring and equipment. |
Isolated |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
04/01/2005 |
exits that are free from obstructions and can be used at all times. |
Pattern |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
04/01/2005 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Pattern |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
04/01/2005 |
emergency lighting that can last at least 1 1/2 hours. |
Isolated |
Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
04/01/2005 |
proper medical gas storage and administration areas. |
Isolated |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
06/22/2006 |
an approved automatic sprinkler system connected to the fire alarm system. |
Isolated |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
06/22/2006 |
heating and ventilation systems that have been properly installed according to the manufacturer's instructions. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
06/22/2006 |
properly installed electrical wiring and equipment. |
Isolated |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
06/22/2006 |
exits that are free from obstructions and can be used at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
06/22/2006 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Isolated |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
06/22/2006 |
proper backup exit lighting. |
Isolated |
Minimal harm or potential for actual harm |