| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
06/10/2004 |
Follow all laws and professional standards. |
Pattern |
Potential for minimal harm |
| Administration Deficiencies |
06/10/2004 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/10/2004 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/10/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/10/2004 |
Get rid of garbage properly. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/10/2004 |
Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/10/2004 |
Provide bedrooms that don't allow residents to see each other when privacy is needed. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/10/2004 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
06/10/2004 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/10/2004 |
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 |
06/10/2004 |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/10/2004 |
Keep drugs and other similar products locked safely and properly stored. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/10/2004 |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/10/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/10/2004 |
Give the right treatment and services to residents who have mental or social problems adjusting. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/10/2004 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/10/2004 |
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 Assessment Deficiencies |
06/10/2004 |
Check and update (if needed) each resident's assessment every 3 months. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/10/2004 |
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 |
06/10/2004 |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/10/2004 |
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 |
06/10/2004 |
Make sure that doctors visit residents regularly, as required. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/10/2004 |
Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/10/2004 |
Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/10/2004 |
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 |
| Resident Rights Deficiencies |
06/10/2004 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/10/2004 |
Send and promptly deliver unopened mail to residents. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/10/2004 |
Let residents give themselves their drugs if they are able. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/10/2004 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
05/11/2005 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Widespread |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
05/11/2005 |
Protect residents from mistreatment, neglect, and/or theft of personal property. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
05/11/2005 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/11/2005 |
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 |
05/11/2005 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/11/2005 |
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 |
05/11/2005 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Pattern |
Actual harm |
| Quality Care Deficiencies |
05/11/2005 |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/11/2005 |
Use a registered nurse at least 8 hours a day, 7 days a week. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
05/11/2005 |
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 |
05/11/2005 |
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
05/11/2005 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
05/11/2005 |
Keep each resident's personal and medical records private and confidential. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/16/2006 |
Follow all laws and professional standards. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/16/2006 |
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/16/2006 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/16/2006 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
03/16/2006 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
03/16/2006 |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/16/2006 |
Provide activities to meet the needs of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/16/2006 |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/16/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/16/2006 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/16/2006 |
Check and update (if needed) each resident's assessment every 3 months. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/16/2006 |
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 |
| Resident Assessment Deficiencies |
03/16/2006 |
Keep assessments completed in the preceding 15 months in the resident's active record. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/16/2006 |
Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/16/2006 |
Make sure that doctors visit residents regularly, as required. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/16/2006 |
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/16/2006 |
Provide proof that all residents' personal money which is deposited with the nursing home, is secure. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/16/2006 |
Allow residents to easily see the results of the nursing home's most recent survey. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
03/16/2006 |
Have a private telephone available for use. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/16/2006 |
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 |
03/16/2006 |
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: |
| Exits and Egress Deficiencies |
06/10/2004 |
exit stairways and towers that are smoke proof. |
Widespread |
Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
06/10/2004 |
proper medical gas storage and administration areas. |
Pattern |
Minimal harm or potential for actual harm |
| Miscellaneous Deficiencies |
06/10/2004 |
fire safety features required by current fire safety codes. |
Pattern |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
06/10/2004 |
proper construction of ducts through walls designed to prevent smoke passage. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
05/18/2005 |
an approved installation, maintenance and testing program for fire alarm systems. |
Widespread |
Minimal harm or potential for actual harm |