| Percent of High Risk Long Term Nursing Home Residents Who Have Pressure Sores: 9% |
| Percent of Long Term Nursing Home Residents Given Influenza Vaccination During the Flu Season: 90+% |
| Percent of Long Term Nursing Home Residents Who are More Depressed or Anxious: 18% |
| Percent of Long Term Nursing Home Residents Who Have Moderate to Severe Pain: 7% |
| Percent of Long Term Nursing Home Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 10% |
| Percent of Long Term Nursing Home Residents Who Lose Too Much Weight: 4% |
| Percent of Long Term Nursing Home Residents Who Spend Most of Their Time in Bed or in a Chair: 1% |
| Percent of Long Term Nursing Home Residents Who Were Assessed and Given Pneumococcal Vaccination: 84% |
| Percent of Long Term Nursing Home Residents Who Were Physically Restrained: 16% |
| Percent of Long Term Nursing Home Residents Whose Ability to Move About in and Around Their Room Got Worse: 20% |
| Percent of Long Term Nursing Home Residents Whose Need for Help With Daily Activities Has Increased: 13% |
| Percent of Long Term Nursing Home Residents With a Urinary Tract Infection: 9% |
| Percent of Low-Risk Long Term Nursing Home Residents Who Have Pressure Sores: 6% |
| Percent of Low-Risk Long Term Nursing Home Residents Who Lose Control of Their Bowels or Bladder: 53% |
| Percent of Short Term Nursing Home Residents Given Influenza Vaccination During the Flu Season: 90+% |
| Percent of Short Term Nursing Home Residents Who Had Moderate to Severe Pain: 40% |
| Percent of Short Term Nursing Home Residents Who Were Assessed and Given Pneumococcal Vaccination: 89% |
| Percent of Short Term Nursing Home Residents With Delirium: 0% |
| Percent of Short Term Nursing Home Residents With Pressure Sores: 29% |
Nursing Home Violations by Trinity Mission Health & Rehab Holly
|
| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
07/11/2003 |
Give or get lab tests to meet the needs of residents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/11/2003 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/11/2003 |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/11/2003 |
Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/11/2003 |
Provide bedrooms that don't allow residents to see each other when privacy is needed. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/11/2003 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Potential for minimal harm |
| Quality Care Deficiencies |
07/11/2003 |
Provide activities to meet the needs of each resident. |
Pattern |
Potential for minimal harm |
| Quality Care Deficiencies |
07/11/2003 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/11/2003 |
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 |
07/11/2003 |
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/11/2003 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
07/11/2003 |
Make sure that doctors visit residents regularly, as required. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/11/2003 |
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 |
| Environmental Deficiencies |
09/10/2004 |
Keep safe, clean and homelike surroundings. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
09/10/2004 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
09/10/2004 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
09/10/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
09/10/2004 |
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 |
09/10/2004 |
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
09/10/2004 |
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 Rights Deficiencies |
09/10/2004 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/18/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/18/2005 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/18/2005 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
11/18/2005 |
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 |
11/18/2005 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/18/2005 |
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 |
11/18/2005 |
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/18/2005 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
11/18/2005 |
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
11/18/2005 |
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 |
11/18/2005 |
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 |
11/18/2005 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |