| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
06/18/2004 |
Quickly tell the resident's doctor the results of lab tests. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
06/18/2004 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/18/2004 |
Provide needed housekeeping and maintenance. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/18/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/18/2004 |
Make sure there is a program to prevent/deal with mice, insects, or other pests. |
Widespread |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
06/18/2004 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
06/18/2004 |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/18/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/18/2004 |
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 |
06/18/2004 |
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 |
06/18/2004 |
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 Assessment Deficiencies |
06/18/2004 |
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 |
06/18/2004 |
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
12/16/2004 |
Follow all laws and professional standards. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
12/16/2004 |
Provide needed housekeeping and maintenance. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
12/16/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
12/16/2004 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
12/16/2004 |
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 |
| Pharmacy Service Deficiencies |
12/16/2004 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
12/16/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
12/16/2004 |
Give each resident a special diet to help when there is a nutritional problem. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
12/16/2004 |
Try to resolve each resident's complaints quickly. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
12/16/2004 |
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 |
| Resident Rights Deficiencies |
12/16/2004 |
Listen to the resident or family groups or act on their complaints or suggestions. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
12/16/2004 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/02/2006 |
Provide needed housekeeping and maintenance. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/02/2006 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
03/02/2006 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
03/02/2006 |
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 |
03/02/2006 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
03/02/2006 |
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 |
03/02/2006 |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
03/02/2006 |
Act when the pharmacist reports something unusual. |
Widespread |
Potential for minimal harm |
| Pharmacy Service Deficiencies |
03/02/2006 |
Keep drugs and other similar products locked safely and properly stored. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/02/2006 |
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 |
03/02/2006 |
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 |
03/02/2006 |
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/02/2006 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/02/2006 |
Have a private telephone available for use. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/02/2006 |
Let residents give themselves their drugs if they are able. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/02/2006 |
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 |
03/02/2006 |
Provide services to meet the needs and preferences of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Automatic Sprinkler Systems Deficiencies |
06/15/2004 |
automatic sprinkler systems that have been maintained in working order. |
Widespread |
Minimal harm or potential for actual harm |
| Building Contruction Deficiencies |
12/16/2004 |
approved construction type or materials. |
Isolated |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
02/27/2006 |
properly protected cooking facilities. |
Isolated |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
02/27/2006 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
02/27/2006 |
an approved installation, maintenance and testing program for fire alarm systems. |
Widespread |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
02/27/2006 |
exits that are free from obstructions and can be used at all times. |
Widespread |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
02/27/2006 |
at least two compartments on every floor to protect residents from smoke. |
Widespread |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
02/27/2006 |
proper construction of ducts through walls designed to prevent smoke passage. |
Widespread |
Minimal harm or potential for actual harm |