| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
06/11/2004 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/11/2004 |
Provide bedrooms that don't allow residents to see each other when privacy is needed. |
Pattern |
Potential for minimal harm |
| Environmental Deficiencies |
06/11/2004 |
Make sure that a working call system is available in each resident's room or bathroom and bathing area. |
Pattern |
Potential for minimal harm |
| Mistreatment Deficiencies |
06/11/2004 |
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 |
| Mistreatment Deficiencies |
06/11/2004 |
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 |
06/11/2004 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/11/2004 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/11/2004 |
Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
06/11/2004 |
Act when the pharmacist reports something unusual. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/11/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/11/2004 |
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 |
06/11/2004 |
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 Rights Deficiencies |
06/11/2004 |
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. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
06/11/2004 |
Provide care for each resident in a way that keeps or builds the resident's quality of life. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
07/28/2005 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/28/2005 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/28/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/28/2005 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/28/2005 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
07/28/2005 |
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 |
07/28/2005 |
Provide food in a way that meets a resident's needs. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/28/2005 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/28/2005 |
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 |
07/28/2005 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
07/28/2005 |
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 |
07/28/2005 |
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 |
| Administration Deficiencies |
08/25/2006 |
Give or get lab tests to meet the needs of residents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/25/2006 |
Keep safe, clean and homelike surroundings. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
08/25/2006 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/25/2006 |
Keep temperature levels comfortable and safe. |
Pattern |
Potential for minimal harm |
| Environmental Deficiencies |
08/25/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
08/25/2006 |
Provide enough emergency electricity. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
08/25/2006 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
08/25/2006 |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
08/25/2006 |
Properly mark drugs and other similar products. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
08/25/2006 |
Provide activities to meet the needs of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
08/25/2006 |
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 |
08/25/2006 |
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 |
08/25/2006 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
08/25/2006 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
08/25/2006 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Pattern |
Potential for minimal harm |
| Resident Assessment Deficiencies |
08/25/2006 |
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 |
08/25/2006 |
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 |
08/25/2006 |
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
08/25/2006 |
Allow residents to easily see the results of the nursing home's most recent survey. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
08/25/2006 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Corridor Walls and Doors Deficiencies |
05/05/2004 |
corridors that are separated from common areas by walls constructed to limit the passage of smoke. |
Widespread |
Potential for minimal harm |
| Hazardous Area Deficiencies |
05/05/2004 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Widespread |
Potential for minimal harm |
| Corridor Walls and Doors Deficiencies |
06/28/2006 |
corridor and hallway doors that block smoke. |
Pattern |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
06/28/2006 |
properly installed electrical wiring and equipment. |
Isolated |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
06/28/2006 |
did not have a written emergency evacuation plan. |
Widespread |
Potential for minimal harm |
| Emergency Plans and Fire Drills Deficiencies |
06/28/2006 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
06/28/2006 |
exits that are accessible at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
06/28/2006 |
an approved back-up procedure for a faulty fire alarm system. |
Widespread |
Potential for minimal harm |
| Hazardous Area Deficiencies |
06/28/2006 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Isolated |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
06/28/2006 |
emergency lighting that can last at least 1 1/2 hours. |
Isolated |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
06/28/2006 |
properly located and lighted Exit signs. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
06/28/2006 |
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. |
Isolated |
Minimal harm or potential for actual harm |