| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
01/15/2004 |
Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/15/2004 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/15/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/15/2004 |
Have a program to keep infection from spreading. |
Widespread |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
01/15/2004 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/15/2004 |
Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/15/2004 |
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 |
01/15/2004 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
01/15/2004 |
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 |
01/15/2004 |
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 |
01/15/2004 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
01/15/2004 |
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 |
| Mistreatment Deficiencies |
01/12/2005 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
01/12/2005 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
01/12/2005 |
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 |
| Quality Care Deficiencies |
01/12/2005 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/12/2005 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Immediate jeopardy to resident health or safety |
| Quality Care Deficiencies |
01/12/2005 |
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 |
01/12/2005 |
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 |
| Administration Deficiencies |
12/08/2005 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
12/08/2005 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
12/08/2005 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
12/08/2005 |
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 |
12/08/2005 |
Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
12/08/2005 |
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 |
| Resident Assessment Deficiencies |
12/08/2005 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
12/08/2005 |
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
12/08/2005 |
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 |
12/08/2005 |
Let the resident refuse treatment or refuse to take part in an experiment. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Building Service Equipment Deficiencies |
02/01/2005 |
an elevator that firefighters can control in the event of a fire. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
02/01/2005 |
weekly inspections and monthly testing of generators. |
Isolated |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
02/01/2005 |
properly installed electrical wiring and equipment. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
02/01/2005 |
a fire alarm system that can be heard throughout the facility. |
Isolated |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
02/01/2005 |
properly sized and located linen or trash receptacles. |
Isolated |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
10/12/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Pattern |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
10/12/2005 |
automatic sprinkler systems that have been maintained in working order. |
Widespread |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
10/12/2005 |
properly protected cooking facilities. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
10/12/2005 |
corridor and hallway doors that block smoke. |
Pattern |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
10/12/2005 |
exits that are accessible at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
10/12/2005 |
a fire alarm system that can be heard throughout the facility. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
10/12/2005 |
an approved installation, maintenance and testing program for fire alarm systems. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
10/12/2005 |
properly maintained smoke detectors. |
Widespread |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
10/12/2005 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Pattern |
Minimal harm or potential for actual harm |
| Interior Finish Deficiencies |
10/12/2005 |
fire-resistant room wall surfaces. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
10/12/2005 |
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 |
| Smoking Regulations Deficiencies |
10/12/2005 |
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 |