| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Environmental Deficiencies |
07/28/2004 |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/28/2004 |
Keep all essential equipment working safely. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
07/28/2004 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
07/28/2004 |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/28/2004 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/28/2004 |
Provide proof that all residents' personal money which is deposited with the nursing home, is secure. |
Pattern |
Potential for minimal harm |
| Resident Rights Deficiencies |
07/28/2004 |
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 |
Potential for minimal harm |
| Environmental Deficiencies |
06/23/2005 |
Provide needed housekeeping and maintenance. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
06/23/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/23/2005 |
Get rid of garbage properly. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
06/23/2005 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/23/2005 |
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 |
| Mistreatment Deficiencies |
06/23/2005 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
06/23/2005 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/23/2005 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/11/2006 |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Widespread |
Actual harm |
| Administration Deficiencies |
03/11/2006 |
Follow all laws and professional standards. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/11/2006 |
Give or get lab tests to meet the needs of residents. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/11/2006 |
Quickly tell the resident's doctor the results of x-rays and other tests. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/11/2006 |
Train all employees on what to do in an emergency. |
Widespread |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/11/2006 |
Set up or keep a group of people to review and ensure quality. |
Widespread |
Actual harm |
| Environmental Deficiencies |
03/11/2006 |
Provide needed housekeeping and maintenance. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/11/2006 |
Keep adequate and comfortable lighting in all areas. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/11/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Actual harm |
| Environmental Deficiencies |
03/11/2006 |
Keep all essential equipment working safely. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
03/11/2006 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Actual harm |
| Mistreatment Deficiencies |
03/11/2006 |
Protect each resident from all abuse, physical punishment, and being separated from others. |
Isolated |
Actual harm |
| Mistreatment Deficiencies |
03/11/2006 |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Widespread |
Actual harm |
| Nutrition and Dietary Deficiencies |
03/11/2006 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
03/11/2006 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/11/2006 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/11/2006 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/11/2006 |
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/11/2006 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Pattern |
Actual harm |
| Quality Care Deficiencies |
03/11/2006 |
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. |
Widespread |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/11/2006 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
03/11/2006 |
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 |
03/11/2006 |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Widespread |
Actual harm |
| Quality Care Deficiencies |
03/11/2006 |
Use a registered nurse at least 8 hours a day, 7 days a week. |
Widespread |
Actual harm |
| Resident Assessment Deficiencies |
03/11/2006 |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Isolated |
Actual harm |
| Resident Assessment Deficiencies |
03/11/2006 |
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 |
03/11/2006 |
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 |
Actual harm |
| Resident Rights Deficiencies |
03/11/2006 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Electrical Deficiencies |
06/22/2005 |
properly installed electrical wiring and equipment. |
Widespread |
Minimal harm or potential for actual harm |
| Miscellaneous Deficiencies |
06/22/2005 |
fire safety features required by current fire safety codes. |
Widespread |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
06/22/2005 |
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 |
06/22/2005 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Widespread |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
03/08/2006 |
portable fire extinguishers. |
Widespread |
Potential for minimal harm |
| Smoke Compartmentation and Control Deficiencies |
03/08/2006 |
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. |
Widespread |
Potential for minimal harm |