| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
04/06/2004 |
Give lab tests only when the attending doctor ordered them. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
04/06/2004 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/06/2004 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/06/2004 |
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 |
04/06/2004 |
Keep each resident free from drugs that restrain them, unless needed for medical treatment. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
04/06/2004 |
Make sure that residents are well nourished. |
Pattern |
Potential for minimal harm |
| Nutrition and Dietary Deficiencies |
04/06/2004 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Potential for minimal harm |
| Pharmacy Service Deficiencies |
04/06/2004 |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/06/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/06/2004 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
04/06/2004 |
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/06/2004 |
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 |
04/06/2004 |
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. |
Pattern |
Potential for minimal harm |
| Resident Rights Deficiencies |
04/06/2004 |
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 |
| Resident Rights Deficiencies |
04/06/2004 |
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 |
03/16/2005 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/16/2005 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/16/2005 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/16/2005 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/16/2005 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
03/16/2005 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
03/16/2005 |
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 |
03/16/2005 |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
03/16/2005 |
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 |
Potential for minimal harm |
| Nutrition and Dietary Deficiencies |
03/16/2005 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
03/16/2005 |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/16/2005 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/16/2005 |
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 |
03/16/2005 |
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/16/2005 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/16/2005 |
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/16/2005 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/16/2005 |
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 |
03/16/2005 |
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. |
Pattern |
Potential for minimal harm |
| Resident Rights Deficiencies |
03/16/2005 |
Allow residents to easily see the results of the nursing home's most recent survey. |
Pattern |
Potential for minimal harm |
| Resident Rights Deficiencies |
03/16/2005 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
06/02/2006 |
Quickly tell the resident's doctor the results of lab tests. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
06/02/2006 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/02/2006 |
Provide needed housekeeping and maintenance. |
Pattern |
Potential for minimal harm |
| Environmental Deficiencies |
06/02/2006 |
Keep sound levels comfortable. |
Pattern |
Potential for minimal harm |
| Environmental Deficiencies |
06/02/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/02/2006 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
06/02/2006 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
06/02/2006 |
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 |
06/02/2006 |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
06/02/2006 |
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 |
06/02/2006 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/02/2006 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/02/2006 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
06/02/2006 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/02/2006 |
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/02/2006 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
06/02/2006 |
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/02/2006 |
Give or get dental care for each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/02/2006 |
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 |
| Resident Rights Deficiencies |
06/02/2006 |
Try to resolve each resident's complaints quickly. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Automatic Sprinkler Systems Deficiencies |
04/05/2004 |
automatic sprinkler systems that have been maintained in working order. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
04/05/2004 |
corridor and hallway doors that block smoke. |
Widespread |
Potential for minimal harm |
| Furnishings and Decorations Deficiencies |
04/05/2004 |
properly sized and located linen or trash receptacles. |
Widespread |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
04/05/2004 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Isolated |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
03/16/2005 |
corridors or aisles that are unobstructed and are at least 8 feet in width. |
Isolated |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
03/16/2005 |
proper exit design. |
Isolated |
Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
03/16/2005 |
proper medical gas storage and administration areas. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
03/16/2005 |
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. |
Pattern |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
06/08/2006 |
automatic sprinkler systems that have been maintained in working order. |
Isolated |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
06/08/2006 |
back-up procedures in place for a faulty automatic sprinkler system. |
Widespread |
Potential for minimal harm |
| Corridor Walls and Doors Deficiencies |
06/08/2006 |
corridor and hallway doors that block smoke. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
06/08/2006 |
weekly inspections and monthly testing of generators. |
Widespread |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
06/08/2006 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Potential for minimal harm |
| Fire Alarm Systems Deficiencies |
06/08/2006 |
an approved back-up procedure for a faulty fire alarm system. |
Widespread |
Potential for minimal harm |
| Illumination and Emergency Power Deficiencies |
06/08/2006 |
proper backup exit lighting. |
Widespread |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
06/08/2006 |
emergency lighting that can last at least 1 1/2 hours. |
Widespread |
Minimal harm or potential for actual harm |