| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
11/10/2004 |
Hire a qualified activities director. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
11/10/2004 |
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/10/2004 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/10/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Actual harm |
| Environmental Deficiencies |
11/10/2004 |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/10/2004 |
Make sure that staff members wash their hands when needed. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
11/10/2004 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
11/10/2004 |
Keep drugs and other similar products locked safely and properly stored. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/10/2004 |
Provide activities to meet the needs of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/10/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/10/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/10/2004 |
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 |
| Resident Rights Deficiencies |
11/10/2004 |
Keep each resident's personal and medical records private and confidential. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
11/10/2004 |
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 |
11/10/2004 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
06/09/2005 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2005 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2005 |
Provide clean bed and bath linens that are in good condition. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2005 |
Keep adequate and comfortable lighting in all areas. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2005 |
Keep sound levels comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2005 |
Get rid of garbage properly. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2005 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2005 |
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 |
06/09/2005 |
Keep all essential equipment working safely. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2005 |
Make sure there is a program to prevent/deal with mice, insects, or other pests. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
06/09/2005 |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
06/09/2005 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
06/09/2005 |
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 |
06/09/2005 |
Provide food in a way that meets a resident's needs. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
06/09/2005 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/09/2005 |
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 |
06/09/2005 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/09/2005 |
At least once a month, have a licensed pharmacist check the drugs that each resident takes. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/09/2005 |
Keep drugs and other similar products locked safely and properly stored. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/09/2005 |
Provide activities to meet the needs of each resident. |
Pattern |
Potential for minimal harm |
| Quality Care Deficiencies |
06/09/2005 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/09/2005 |
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 |
06/09/2005 |
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 |
| Resident Assessment Deficiencies |
06/09/2005 |
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 |
06/09/2005 |
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. |
Pattern |
Potential for minimal harm |
| Resident Assessment Deficiencies |
06/09/2005 |
Develop a plan with the resident and family for the resident's care after leaving the nursing home. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/09/2005 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/09/2005 |
Let residents complain without being treated differently or badly. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/09/2005 |
Try to resolve each resident's complaints quickly. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/09/2005 |
Send and promptly deliver unopened mail to residents. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/09/2005 |
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. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
06/09/2005 |
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 |
06/09/2005 |
Provide services to meet the needs and preferences of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
12/16/2005 |
Follow all laws and professional standards. |
Widespread |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
12/16/2005 |
Give or get lab tests to meet the needs of residents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
12/16/2005 |
Keep safe, clean and homelike surroundings. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
12/16/2005 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
12/16/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
12/16/2005 |
Get rid of garbage properly. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
12/16/2005 |
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 |
12/16/2005 |
Keep all essential equipment working safely. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
12/16/2005 |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
12/16/2005 |
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 |
| Quality Care Deficiencies |
12/16/2005 |
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 |
12/16/2005 |
Give each resident care and services to get or keep the highest quality of life possible. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
12/16/2005 |
Give the right treatment and services to residents who have mental or social problems adjusting. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
12/16/2005 |
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 |
12/16/2005 |
Get doctor orders for the resident's immediate care when admitted. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
12/16/2005 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
12/16/2005 |
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 |
12/16/2005 |
Check and update (if needed) each resident's assessment every 3 months. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
12/16/2005 |
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 |
12/16/2005 |
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 |
12/16/2005 |
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 Assessment Deficiencies |
12/16/2005 |
Develop a plan with the resident and family for the resident's care after leaving the nursing home. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
12/16/2005 |
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 |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
12/16/2005 |
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 |
12/16/2005 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
12/16/2005 |
Try to resolve each resident's complaints quickly. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
12/16/2005 |
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: |
| Automatic Sprinkler Systems Deficiencies |
11/09/2004 |
automatic sprinkler systems that have been maintained in working order. |
Isolated |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
11/09/2004 |
heating and ventilation systems that have been properly installed according to the manufacturer's instructions. |
Widespread |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
11/09/2004 |
proper power supply for life support equipment. |
Widespread |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
11/09/2004 |
properly installed electrical wiring and equipment. |
Widespread |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
11/09/2004 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
11/09/2004 |
a fire alarm system that can be heard throughout the facility. |
Pattern |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
11/09/2004 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
06/06/2005 |
weekly inspections and monthly testing of generators. |
Widespread |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
06/06/2005 |
did not have a written emergency evacuation plan. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
06/06/2005 |
properly maintained smoke detectors. |
Widespread |
Potential for minimal harm |
| Illumination and Emergency Power Deficiencies |
06/06/2005 |
emergency lighting that can last at least 1 1/2 hours. |
Widespread |
Minimal harm or potential for actual harm |
| Miscellaneous Deficiencies |
06/06/2005 |
fire safety features required by current fire safety codes. |
Widespread |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
12/12/2005 |
automatic sprinkler systems that have been maintained in working order. |
Widespread |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
12/12/2005 |
did not have a written emergency evacuation plan. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
12/12/2005 |
properly maintained smoke detectors. |
Isolated |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
12/12/2005 |
exits that are free from obstructions and can be used at all times. |
Pattern |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
12/12/2005 |
emergency lighting that can last at least 1 1/2 hours. |
Isolated |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
12/12/2005 |
properly located and lighted Exit signs. |
Pattern |
Minimal harm or potential for actual harm |