| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Pharmacy Service Deficiencies |
03/25/2004 |
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 |
| Pharmacy Service Deficiencies |
03/25/2004 |
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 |
| Quality Care Deficiencies |
03/25/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/25/2004 |
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 Rights Deficiencies |
03/25/2004 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/03/2005 |
Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
03/03/2005 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2006 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2006 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/09/2006 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Widespread |
Potential for minimal harm |
| Pharmacy Service Deficiencies |
06/09/2006 |
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 |
06/09/2006 |
Keep drugs and other similar products locked safely and properly stored. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/09/2006 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/09/2006 |
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 |
06/09/2006 |
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 |
06/09/2006 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/09/2006 |
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 |
| Resident Assessment Deficiencies |
06/09/2006 |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/09/2006 |
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 |
06/09/2006 |
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 |
06/09/2006 |
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
06/09/2006 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Automatic Sprinkler Systems Deficiencies |
03/03/2004 |
automatic sprinkler systems that have been maintained in working order. |
Widespread |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
03/03/2004 |
heating and ventilation systems that have been properly installed according to the manufacturer's instructions. |
Isolated |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
03/03/2004 |
properly protected cooking facilities. |
Isolated |
Minimal harm or potential for actual harm |
| Building Service Equipment Deficiencies |
03/03/2004 |
properly constructed linen or trash chutes. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
03/03/2004 |
corridor and hallway doors that block smoke. |
Pattern |
Potential for minimal harm |
| Exits and Egress Deficiencies |
03/03/2004 |
exits that are accessible at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
03/03/2004 |
a fire alarm system that can be heard throughout the facility. |
Pattern |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
03/03/2004 |
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 |
03/03/2004 |
emergency lighting that can last at least 1 1/2 hours. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
03/03/2004 |
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 |
03/03/2004 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Pattern |
Minimal harm or potential for actual harm |
| Smoking Regulations Deficiencies |
03/03/2004 |
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. |
Pattern |
Potential for minimal harm |
| Automatic Sprinkler Systems Deficiencies |
02/01/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Pattern |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
02/01/2005 |
automatic sprinkler systems that have been maintained in working order. |
Widespread |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
02/01/2005 |
portable fire extinguishers. |
Pattern |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
02/01/2005 |
corridor and hallway doors that block smoke. |
Isolated |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
02/01/2005 |
exits that are accessible at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
02/01/2005 |
properly maintained smoke detectors. |
Pattern |
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 |
| Illumination and Emergency Power Deficiencies |
02/01/2005 |
proper backup exit lighting. |
Pattern |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
02/01/2005 |
emergency lighting that can last at least 1 1/2 hours. |
Isolated |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
02/01/2005 |
properly located and lighted Exit signs. |
Isolated |
Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
02/01/2005 |
proper medical gas storage and administration areas. |
Isolated |
Minimal harm or potential for actual harm |
| Miscellaneous Deficiencies |
02/01/2005 |
fire safety features required by current fire safety codes. |
Pattern |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
02/01/2005 |
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 |
| Smoke Compartmentation and Control Deficiencies |
02/01/2005 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Pattern |
Minimal harm or potential for actual harm |
| Smoking Regulations Deficiencies |
02/01/2005 |
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 |
| Building Contruction Deficiencies |
02/21/2006 |
approved construction type or materials. |
Widespread |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
02/21/2006 |
corridor and hallway doors that block smoke. |
Widespread |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
02/21/2006 |
exits that are accessible at all times. |
Pattern |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
02/21/2006 |
exits that are free from obstructions and can be used at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
02/21/2006 |
emergency lighting that can last at least 1 1/2 hours. |
Isolated |
Minimal harm or potential for actual harm |
| Miscellaneous Deficiencies |
02/21/2006 |
fire safety features required by current fire safety codes. |
Isolated |
Minimal harm or potential for actual harm |
| Smoking Regulations Deficiencies |
02/21/2006 |
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 |
02/21/2006 |
protected exits that allow the resident to escape the building. |
Isolated |
Minimal harm or potential for actual harm |