| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
11/21/2002 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/21/2002 |
Stop employees, who have a disease that can spread, from having direct contact with residents or food. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/21/2002 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/21/2002 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/21/2002 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
11/21/2002 |
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 Rights Deficiencies |
11/21/2002 |
Listen to the resident or family groups or act on their complaints or suggestions. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/22/2004 |
Hire a qualified social worker; or in homes with more than 120 beds, hire a qualified full-time social worker. |
Widespread |
Potential for minimal harm |
| Administration Deficiencies |
01/22/2004 |
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/22/2004 |
Give lab tests only when the attending doctor ordered them. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/22/2004 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
01/22/2004 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Actual harm |
| Mistreatment Deficiencies |
01/22/2004 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
01/22/2004 |
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 |
01/22/2004 |
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 |
01/22/2004 |
Provide drugs and related services needed by each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/22/2004 |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/22/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
01/22/2004 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Resident Assessment Deficiencies |
01/22/2004 |
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. |
Isolated |
Actual harm |
| Resident Assessment Deficiencies |
01/22/2004 |
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 |
| Resident Rights Deficiencies |
01/22/2004 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
11/23/2004 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/23/2004 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/23/2004 |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/23/2004 |
Offer other nutritional food to each resident who will not eat the food served. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/23/2004 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Immediate jeopardy to resident health or safety |
| Quality Care Deficiencies |
11/23/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/23/2004 |
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 |
11/23/2004 |
Send and promptly deliver unopened mail to residents. |
Pattern |
Potential for minimal harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Corridor Walls and Doors Deficiencies |
11/19/2002 |
corridors that are separated from common areas by walls constructed to limit the passage of smoke. |
Widespread |
Potential for minimal harm |
| Smoke Compartmentation and Control Deficiencies |
01/20/2004 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Widespread |
Potential for minimal harm |
| Corridor Walls and Doors Deficiencies |
11/23/2004 |
corridors that are separated from common areas by walls constructed to limit the passage of smoke. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
11/23/2004 |
a fire alarm system that can be heard throughout the facility. |
Pattern |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
11/23/2004 |
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 |