| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Mistreatment Deficiencies |
10/21/2004 |
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 |
10/21/2004 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
10/21/2004 |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
10/21/2004 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
10/21/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
10/21/2004 |
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 |
10/21/2004 |
Give each resident a special diet to help when there is a nutritional problem. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
10/21/2004 |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
10/21/2004 |
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 |
10/21/2004 |
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 |
10/21/2004 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
10/21/2004 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
08/12/2005 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/12/2005 |
Keep safe, clean and homelike surroundings. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/12/2005 |
Provide needed housekeeping and maintenance. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/12/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/12/2005 |
Make sure that staff members wash their hands when needed. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/12/2005 |
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 |
08/12/2005 |
Keep all essential equipment working safely. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
08/12/2005 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
08/12/2005 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
08/12/2005 |
Hire enough skilled workers to carry out dietary service. |
Widespread |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
08/12/2005 |
Make sure that residents are well nourished. |
Widespread |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
08/12/2005 |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Widespread |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
08/12/2005 |
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 |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
08/12/2005 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
08/12/2005 |
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 |
08/12/2005 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
08/12/2005 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
08/12/2005 |
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 |
| Quality Care Deficiencies |
08/12/2005 |
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 |
08/12/2005 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
08/12/2005 |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
08/12/2005 |
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 |
08/12/2005 |
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 |
08/12/2005 |
Keep assessments completed in the preceding 15 months in the resident's active record. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
08/12/2005 |
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 |
Potential for minimal harm |
| Resident Rights Deficiencies |
08/12/2005 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
08/12/2005 |
Try to resolve each resident's complaints quickly. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
08/12/2005 |
Send and promptly deliver unopened mail to residents. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
08/12/2005 |
Let residents give themselves their drugs if they are able. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
08/12/2005 |
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 |
08/12/2005 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
07/28/2006 |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Pattern |
Actual harm |
| Environmental Deficiencies |
07/28/2006 |
Provide needed housekeeping and maintenance. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/28/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
07/28/2006 |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Pattern |
Actual harm |
| Nutrition and Dietary Deficiencies |
07/28/2006 |
Hire enough skilled workers to carry out dietary service. |
Widespread |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/28/2006 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
07/28/2006 |
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 |
07/28/2006 |
Keep drugs and other similar products locked safely and properly stored. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/28/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
07/28/2006 |
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 |
07/28/2006 |
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 |
07/28/2006 |
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 |
07/28/2006 |
Check and update (if needed) each resident's assessment every 3 months. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
07/28/2006 |
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 |
07/28/2006 |
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 |
07/28/2006 |
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 Rights Deficiencies |
07/28/2006 |
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 |
| Resident Rights Deficiencies |
07/28/2006 |
Quickly give a resident's personal money to the heads of his or her estate after the resident's death. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
07/28/2006 |
Let residents give themselves their drugs if they are able. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/28/2006 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Emergency Plans and Fire Drills Deficiencies |
08/09/2005 |
did not have a written emergency evacuation plan. |
Widespread |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
07/27/2006 |
an approved automatic sprinkler system connected to the fire alarm system. |
Widespread |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
07/27/2006 |
record of quarterly fire drills for each shift under varying conditions. |
Pattern |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
07/27/2006 |
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. |
Pattern |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
07/27/2006 |
proper construction of ducts through walls designed to prevent smoke passage. |
Widespread |
Minimal harm or potential for actual harm |