| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Environmental Deficiencies |
02/26/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
02/26/2004 |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
02/26/2004 |
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 |
02/26/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/26/2004 |
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 |
02/26/2004 |
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 |
02/26/2004 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
02/26/2004 |
Give or get special rehabilitation if in the patient's plan of care. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
02/26/2004 |
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 |
02/26/2004 |
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 |
| Resident Assessment Deficiencies |
02/26/2004 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
02/22/2005 |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Pattern |
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 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/22/2005 |
Provide activities to meet the needs of each resident. |
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 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 |
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 |
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 |
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 |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/22/2005 |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
02/22/2005 |
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 |
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 Assessment Deficiencies |
02/22/2005 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/22/2005 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/22/2005 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Isolated |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/22/2005 |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/05/2006 |
Get proof that a nurse aide has the training and skills that the State requires. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
01/05/2006 |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/05/2006 |
Provide activities to meet the needs of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/05/2006 |
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 |
01/05/2006 |
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 |
01/05/2006 |
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 |
01/05/2006 |
Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
01/05/2006 |
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
01/05/2006 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Automatic Sprinkler Systems Deficiencies |
01/10/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Widespread |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
01/10/2005 |
automatic sprinkler systems that have been maintained in working order. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
01/10/2005 |
corridor and hallway doors that block smoke. |
Widespread |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
01/10/2005 |
properly installed electrical wiring and equipment. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
01/10/2005 |
a fire alarm system that can be heard throughout the facility. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
01/10/2005 |
an approved installation, maintenance and testing program for fire alarm systems. |
Widespread |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
01/10/2005 |
exits that are free from obstructions and can be used at all times. |
Pattern |
Minimal harm or potential for actual harm |
| Hazardous Area Deficiencies |
01/10/2005 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Isolated |
Minimal harm or potential for actual harm |
| Illumination and Emergency Power Deficiencies |
01/10/2005 |
emergency lighting that can last at least 1 1/2 hours. |
Isolated |
Minimal harm or potential for actual harm |
| Laboratories Deficiencies |
01/10/2005 |
emergency showers. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
01/10/2005 |
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 |
| Smoking Regulations Deficiencies |
01/10/2005 |
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. |
Widespread |
Minimal harm or potential for actual harm |
| Vertical Openings Deficiencies |
01/10/2005 |
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 |