| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Environmental Deficiencies |
02/12/2004 |
Provide needed housekeeping and maintenance. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
02/12/2004 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Widespread |
Potential for minimal harm |
| Mistreatment Deficiencies |
02/12/2004 |
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 |
| Pharmacy Service Deficiencies |
02/12/2004 |
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 |
| Quality Care Deficiencies |
02/12/2004 |
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 |
02/12/2004 |
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 |
02/12/2004 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
02/12/2004 |
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 |
02/12/2004 |
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 |
02/12/2004 |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
02/12/2004 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
02/12/2004 |
Do a new assessment after any major change in a resident's physical or mental health. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
02/12/2004 |
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. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/12/2004 |
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 |
02/12/2004 |
Provide proof that all residents' personal money which is deposited with the nursing home, is secure. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/22/2005 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/22/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/22/2005 |
Make sure that a working call system is available in each resident's room or bathroom and bathing area. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
02/22/2005 |
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 |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
02/22/2005 |
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 |
| Quality Care Deficiencies |
02/22/2005 |
Provide activities to meet the needs of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/22/2005 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/22/2005 |
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 |
02/22/2005 |
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 |
02/22/2005 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
02/22/2005 |
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/22/2005 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/22/2005 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
02/22/2005 |
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 |
| Quality Care Deficiencies |
02/22/2005 |
Use a registered nurse at least 8 hours a day, 7 days a week. |
Widespread |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
02/22/2005 |
Check and update (if needed) each resident's assessment every 3 months. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
02/22/2005 |
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 |
02/22/2005 |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/22/2005 |
Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/22/2005 |
Provide services to meet the needs and preferences of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/25/2006 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/25/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/25/2006 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Potential for minimal harm |
| Nutrition and Dietary Deficiencies |
01/25/2006 |
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 |
| Quality Care Deficiencies |
01/25/2006 |
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 |
01/25/2006 |
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/25/2006 |
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 |
| Resident Assessment Deficiencies |
01/25/2006 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Automatic Sprinkler Systems Deficiencies |
01/04/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Pattern |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
01/04/2005 |
properly working alarms on sprinkler valves. |
Isolated |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
01/04/2005 |
automatic sprinkler systems that have been maintained in working order. |
Pattern |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
01/04/2005 |
corridor and hallway doors that block smoke. |
Pattern |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
01/04/2005 |
did not have a written emergency evacuation plan. |
Pattern |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
01/04/2005 |
record of quarterly fire drills for each shift under varying conditions. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
01/04/2005 |
properly maintained smoke detectors. |
Pattern |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
01/04/2005 |
properly sized and located linen or trash receptacles. |
Pattern |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
01/04/2005 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Pattern |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
01/04/2005 |
properly located and lighted Exit signs. |
Isolated |
Minimal harm or potential for actual harm |
| Interior Finish Deficiencies |
01/04/2005 |
fire-resistant interior walls. |
Pattern |
Minimal harm or potential for actual harm |
| Interior Finish Deficiencies |
01/04/2005 |
fire-resistant room wall surfaces. |
Isolated |
Minimal harm or potential for actual harm |
| Miscellaneous Deficiencies |
01/04/2005 |
fire safety features required by current fire safety codes. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
01/04/2005 |
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 |
| Smoke Compartmentation and Control Deficiencies |
01/04/2005 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Isolated |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
11/28/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Pattern |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
11/28/2005 |
automatic sprinkler systems that have been maintained in working order. |
Widespread |
Minimal harm or potential for actual harm |
| Building Contruction Deficiencies |
11/28/2005 |
approved construction type or materials. |
Widespread |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
11/28/2005 |
properly protected cooking facilities. |
Widespread |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
11/28/2005 |
corridor and hallway doors that block smoke. |
Widespread |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
11/28/2005 |
properly installed electrical wiring and equipment. |
Widespread |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
11/28/2005 |
did not have a written emergency evacuation plan. |
Widespread |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
11/28/2005 |
record of quarterly fire drills for each shift under varying conditions. |
Isolated |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
11/28/2005 |
exits that are accessible at all times. |
Pattern |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
11/28/2005 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Pattern |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
11/28/2005 |
proper backup exit lighting. |
Pattern |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
11/28/2005 |
emergency lighting that can last at least 1 1/2 hours. |
Isolated |
Minimal harm or potential for actual harm |
| Interior Finish Deficiencies |
11/28/2005 |
fire-resistant room wall surfaces. |
Isolated |
Minimal harm or potential for actual harm |
| Laboratories Deficiencies |
11/28/2005 |
emergency showers. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
11/28/2005 |
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. |
Widespread |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
11/28/2005 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Isolated |
Minimal harm or potential for actual harm |
| Smoking Regulations Deficiencies |
11/28/2005 |
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. |
Isolated |
Minimal harm or potential for actual harm |
| Vertical Openings Deficiencies |
11/28/2005 |
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 |