| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
04/29/2004 |
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/29/2004 |
Keep safe, clean and homelike surroundings. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/29/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/29/2004 |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
04/29/2004 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
04/29/2004 |
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 |
| Nutrition and Dietary Deficiencies |
04/29/2004 |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Potential for minimal harm |
| Pharmacy Service Deficiencies |
04/29/2004 |
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 |
04/29/2004 |
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 Assessment Deficiencies |
04/29/2004 |
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 |
04/29/2004 |
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 |
| Administration Deficiencies |
04/15/2005 |
Give or get lab tests to meet the needs of residents. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
04/15/2005 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
04/15/2005 |
Set up or keep a group of people to review and ensure quality. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/15/2005 |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/15/2005 |
Keep all essential equipment working safely. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
04/15/2005 |
Protect each resident from all abuse, physical punishment, and being separated from others. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
04/15/2005 |
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 |
| Mistreatment Deficiencies |
04/15/2005 |
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 |
| Pharmacy Service Deficiencies |
04/15/2005 |
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 |
04/15/2005 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
04/15/2005 |
Assess the resident when the resident enters the nursing home, in a timely manner. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
04/15/2005 |
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 |
04/15/2005 |
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 Assessment Deficiencies |
04/15/2005 |
Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
02/16/2006 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/16/2006 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
02/16/2006 |
Properly mark drugs and other similar products. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
02/16/2006 |
Keep drugs and other similar products locked safely and properly stored. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/16/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/16/2006 |
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 |
02/16/2006 |
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. |
Pattern |
Potential for minimal harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Electrical Deficiencies |
04/27/2004 |
weekly inspections and monthly testing of generators. |
Widespread |
Minimal harm or potential for actual harm |
| Electrical Deficiencies |
04/27/2004 |
properly installed electrical wiring and equipment. |
Pattern |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
04/27/2004 |
exits that are accessible at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
04/13/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Isolated |
Minimal harm or potential for actual harm |
| Corridor Walls and Doors Deficiencies |
04/13/2005 |
corridor and hallway doors that block smoke. |
Isolated |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
04/13/2005 |
exits that are accessible at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
04/13/2005 |
no-smoking signs where oxygen is used. |
Isolated |
Minimal harm or potential for actual harm |
| Vertical Openings Deficiencies |
04/13/2005 |
proper stairway enclosures and vertical shafts. |
Pattern |
Minimal harm or potential for actual harm |
| Automatic Sprinkler Systems Deficiencies |
02/15/2006 |
automatic sprinkler systems that have been maintained in working order. |
Pattern |
Minimal harm or potential for actual harm |
| Exits and Egress Deficiencies |
02/15/2006 |
exits that are accessible at all times. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
02/15/2006 |
an approved installation, maintenance and testing program for fire alarm systems. |
Widespread |
Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
02/15/2006 |
no-smoking signs where oxygen is used. |
Pattern |
Minimal harm or potential for actual harm |
| Medical Gases and Anesthetizing Areas Deficiencies |
02/15/2006 |
proper fire barriers, ventilation and signs for the transport of oxygen. |
Pattern |
Minimal harm or potential for actual harm |
| Miscellaneous Deficiencies |
02/15/2006 |
fire safety features required by current fire safety codes. |
Widespread |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
02/15/2006 |
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 |