| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
11/04/2004 |
Get services outside the nursing home that meet professional standards. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/04/2004 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/04/2004 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/04/2004 |
Keep all essential equipment working safely. |
Widespread |
Potential for minimal harm |
| Mistreatment Deficiencies |
11/04/2004 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/04/2004 |
Provide food in a way that meets a resident's needs. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/04/2004 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
11/04/2004 |
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 |
11/04/2004 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
11/04/2004 |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
11/04/2004 |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/04/2004 |
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 |
11/04/2004 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/04/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/04/2004 |
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 |
11/04/2004 |
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/04/2004 |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/04/2004 |
Give or get dental care for each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
11/04/2004 |
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 |
11/04/2004 |
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 |
11/04/2004 |
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 |
11/04/2004 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Isolated |
Actual harm |
| Environmental Deficiencies |
05/19/2005 |
Keep safe, clean and homelike surroundings. |
Pattern |
Potential for minimal harm |
| Environmental Deficiencies |
05/19/2005 |
Get rid of garbage properly. |
Widespread |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
05/19/2005 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
05/19/2005 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
05/19/2005 |
Make sure that residents are well nourished. |
Pattern |
Potential for minimal harm |
| Nutrition and Dietary Deficiencies |
05/19/2005 |
Provide food in a way that meets a resident's needs. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
05/19/2005 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
05/19/2005 |
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 |
05/19/2005 |
Provide drugs and related services needed by each resident. |
Pattern |
Potential for minimal harm |
| Quality Care Deficiencies |
05/19/2005 |
Provide activities to meet the needs of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/19/2005 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/19/2005 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/19/2005 |
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 |
05/19/2005 |
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 |
05/19/2005 |
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 |
05/19/2005 |
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 |
05/19/2005 |
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 |
05/19/2005 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
07/13/2006 |
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 |
07/13/2006 |
Get services outside the nursing home that meet professional standards. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/13/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/13/2006 |
Have a program to keep infection from spreading. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/13/2006 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Widespread |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/13/2006 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/13/2006 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/13/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/13/2006 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
07/13/2006 |
Get doctor orders for the resident's immediate care when admitted. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
07/13/2006 |
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 |
07/13/2006 |
Keep assessments completed in the preceding 15 months in the resident's active record. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/13/2006 |
Give the resident's legal representative the same rights as the resident. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/13/2006 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/13/2006 |
Try to resolve each resident's complaints quickly. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/13/2006 |
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 |
11/03/2004 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
11/03/2004 |
exits that are accessible at all times. |
Widespread |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
11/03/2004 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Widespread |
Minimal harm or potential for actual harm |
| Miscellaneous Deficiencies |
11/03/2004 |
fire safety features required by current fire safety codes. |
Widespread |
Minimal harm or potential for actual harm |
| Smoking Regulations Deficiencies |
11/03/2004 |
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. |
Widespread |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
05/17/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Isolated |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
05/17/2005 |
automatic sprinkler systems that have been maintained in working order. |
Widespread |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
05/17/2005 |
heating and ventilation systems that have been properly installed according to the manufacturer's instructions. |
Pattern |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
05/17/2005 |
properly protected cooking facilities. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
05/17/2005 |
properly installed electrical wiring and equipment. |
Isolated |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
05/17/2005 |
did not have a written emergency evacuation plan. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
05/17/2005 |
properly maintained smoke detectors. |
Widespread |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
05/17/2005 |
exits that are free from obstructions and can be used at all times. |
Isolated |
Minimal harm or potential for actual harm |