| Percent of High Risk Long Term Nursing Home Residents Who Have Pressure Sores: 26% |
| 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: 12% |
| Percent of Long Term Nursing Home Residents Who Have Moderate to Severe Pain: 6% |
| Percent of Long Term Nursing Home Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 2% |
| Percent of Long Term Nursing Home Residents Who Lose Too Much Weight: 8% |
| 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: 90% |
| Percent of Long Term Nursing Home Residents Who Were Physically Restrained: 17% |
| Percent of Long Term Nursing Home Residents Whose Ability to Move About in and Around Their Room Got Worse: 21% |
| Percent of Long Term Nursing Home Residents Whose Need for Help With Daily Activities Has Increased: 25% |
| Percent of Long Term Nursing Home Residents With a Urinary Tract Infection: 4% |
| Percent of Low-Risk Long Term Nursing Home Residents Who Have Pressure Sores: 3% |
| Percent of Low-Risk Long Term Nursing Home Residents Who Lose Control of Their Bowels or Bladder: 44% |
| Percent of Short Term Nursing Home Residents Given Influenza Vaccination During the Flu Season: 69% |
| Percent of Short Term Nursing Home Residents Who Had Moderate to Severe Pain: 26% |
| Percent of Short Term Nursing Home Residents Who Were Assessed and Given Pneumococcal Vaccination: 66% |
| Percent of Short Term Nursing Home Residents With Delirium: 2% |
| Percent of Short Term Nursing Home Residents With Pressure Sores: 20% |
Nursing Home Violations by St Mary Healthcare Center
|
| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Environmental Deficiencies |
11/19/2004 |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/19/2004 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/19/2004 |
Give professional services that follow each resident's written care plan. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/19/2004 |
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 |
11/19/2004 |
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 |
11/19/2004 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/19/2004 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Actual harm |
| Resident Rights Deficiencies |
11/19/2004 |
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 |
Actual harm |
| Administration Deficiencies |
01/24/2006 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/24/2006 |
Give or get lab tests to meet the needs of residents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/24/2006 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Exit and Exit Access Deficiencies |
01/26/2004 |
at least two remote exits on each floor or fire section of the building. |
Isolated |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
01/26/2004 |
properly sized and located linen or trash receptacles. |
Pattern |
Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
01/26/2004 |
proper fire barriers, ventilation and signs for the transport of oxygen. |
Isolated |
Minimal harm or potential for actual harm |
| Vertical Openings Deficiencies |
01/26/2004 |
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
11/15/2004 |
properly maintained smoke detectors. |
Widespread |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
01/23/2006 |
an approved automatic sprinkler system connected to the fire alarm system. |
Pattern |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
01/23/2006 |
portable fire extinguishers. |
Widespread |
Potential for minimal harm |
| Building Service Equipment Deficiencies |
01/23/2006 |
properly protected cooking facilities. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
01/23/2006 |
properly constructed windows in hallway walls or doors. |
Pattern |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
01/23/2006 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Potential for minimal harm |
| Exits and Egress Deficiencies |
01/23/2006 |
proper exit design. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
01/23/2006 |
an approved installation, maintenance and testing program for fire alarm systems. |
Widespread |
Potential for minimal harm |
| Illumination and Emergency Power Deficiencies |
01/23/2006 |
proper backup exit lighting. |
Widespread |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
01/23/2006 |
emergency lighting that can last at least 1 1/2 hours. |
Widespread |
Minimal harm or potential for actual harm |
| Smoking Regulations Deficiencies |
01/23/2006 |
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. |
Pattern |
Minimal harm or potential for actual harm |