| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
09/23/2004 |
Hire nurse aides who have completed required training and shown that they are skilled. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
09/23/2004 |
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
09/23/2004 |
Train all employees on what to do in an emergency. |
Pattern |
Immediate jeopardy to resident health or safety |
| Environmental Deficiencies |
09/23/2004 |
Provide bedrooms that don't allow residents to see each other when privacy is needed. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
09/23/2004 |
Make sure that residents are well nourished. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
09/23/2004 |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
09/23/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
09/23/2004 |
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 |
| Resident Assessment Deficiencies |
09/23/2004 |
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 |
09/23/2004 |
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 |
09/23/2004 |
Let residents give themselves their drugs if they are able. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
09/23/2004 |
Provide enough notice before discharging or transferring a resident. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
09/23/2004 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
09/23/2004 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
09/23/2004 |
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 |
04/07/2005 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
04/07/2005 |
Set up or keep a group of people to review and ensure quality. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/07/2005 |
Keep safe, clean and homelike surroundings. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/07/2005 |
Have a program to keep infection from spreading. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/07/2005 |
Keep a resident apart from the others if the resident has an infection that can spread. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/07/2005 |
Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/07/2005 |
Make sure that a working call system is available in each resident's room or bathroom and bathing area. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
04/07/2005 |
Hire enough skilled workers to carry out dietary service. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
04/07/2005 |
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
04/07/2005 |
Act when the pharmacist reports something unusual. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/07/2005 |
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 |
04/07/2005 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/07/2005 |
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 |
04/07/2005 |
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 |
| Resident Assessment Deficiencies |
04/07/2005 |
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 |
04/07/2005 |
Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
04/07/2005 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
05/25/2006 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
05/25/2006 |
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 |
05/25/2006 |
Provide special eating equipment and utensils for each resident who needs them. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
05/25/2006 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
05/25/2006 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/25/2006 |
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 |
05/25/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
05/25/2006 |
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 |
05/25/2006 |
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. |
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 |
09/22/2004 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
09/22/2004 |
exits that are accessible at all times. |
Pattern |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
09/22/2004 |
emergency lighting that can last at least 1 1/2 hours. |
Widespread |
Potential for minimal harm |
| Smoke Compartmentation and Control Deficiencies |
09/22/2004 |
proper construction of ducts through walls designed to prevent smoke passage. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
04/04/2005 |
an approved installation, maintenance and testing program for fire alarm systems. |
Pattern |
Minimal harm or potential for actual harm |