| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
02/03/2004 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/03/2004 |
Provide needed housekeeping and maintenance. |
Pattern |
Potential for minimal harm |
| Environmental Deficiencies |
02/03/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/03/2004 |
Get rid of garbage properly. |
Pattern |
Potential for minimal harm |
| Environmental Deficiencies |
02/03/2004 |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/03/2004 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Widespread |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
02/03/2004 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
02/03/2004 |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/03/2004 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
02/03/2004 |
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 |
02/03/2004 |
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 Assessment Deficiencies |
02/03/2004 |
Keep assessments completed in the preceding 15 months in the resident's active record. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/03/2004 |
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 |
| Environmental Deficiencies |
03/11/2005 |
Provide needed housekeeping and maintenance. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
03/11/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/11/2005 |
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 |
03/11/2005 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/11/2005 |
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 |
03/11/2005 |
Assess the resident when the resident enters the nursing home, in a timely manner. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/11/2005 |
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/11/2005 |
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 |
03/11/2005 |
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 |
03/11/2005 |
Protect the resident from a transfer or discharge that is not wanted or needed. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/11/2005 |
Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/23/2006 |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Widespread |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/23/2006 |
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. |
Pattern |
Potential for minimal harm |
| Administration Deficiencies |
01/23/2006 |
Get services outside the nursing home that meet professional standards. |
Pattern |
Potential for minimal harm |
| Administration Deficiencies |
01/23/2006 |
Choose a doctor to be the medical director. |
Widespread |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/23/2006 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/23/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/23/2006 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
01/23/2006 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
01/23/2006 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/23/2006 |
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 |
01/23/2006 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
01/23/2006 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
01/23/2006 |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
01/23/2006 |
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 |
01/23/2006 |
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 |
01/23/2006 |
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 |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Miscellaneous Deficiencies |
02/11/2004 |
fire safety features required by current fire safety codes. |
Widespread |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
03/17/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Widespread |
Potential for minimal harm |
| Automatic Sprinkler Systems Deficiencies |
03/17/2005 |
automatic sprinkler systems that have been maintained in working order. |
Widespread |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
03/17/2005 |
properly protected cooking facilities. |
Widespread |
Actual harm |
| Corridor Walls and Doors Deficiencies |
03/17/2005 |
corridor and hallway doors that block smoke. |
Widespread |
Potential for minimal harm |
| Electrical Deficiencies |
03/17/2005 |
properly installed electrical wiring and equipment. |
Widespread |
Potential for minimal harm |
| Emergency Plans and Fire Drills Deficiencies |
03/17/2005 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
03/17/2005 |
properly maintained smoke detectors. |
Widespread |
Actual harm |
| Furnishings and Decorations Deficiencies |
03/17/2005 |
exits that are free from obstructions and can be used at all times. |
Widespread |
Actual harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
03/17/2005 |
proper medical gas storage and administration areas. |
Widespread |
Potential for minimal harm |
| Electrical Deficiencies |
12/07/2005 |
properly installed electrical wiring and equipment. |
Widespread |
Potential for minimal harm |
| Emergency Plans and Fire Drills Deficiencies |
12/07/2005 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Potential for minimal harm |
| Fire Alarm Systems Deficiencies |
12/07/2005 |
properly maintained smoke detectors. |
Widespread |
Potential for minimal harm |
| Hazardous Area Deficiencies |
12/07/2005 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Widespread |
Potential for minimal harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
12/07/2005 |
no-smoking signs where oxygen is used. |
Widespread |
Potential for minimal harm |
| Vertical Openings Deficiencies |
12/07/2005 |
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors. |
Widespread |
Potential for minimal harm |