| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
08/12/2004 |
Get proof that a nurse aide has the training and skills that the State requires. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
08/12/2004 |
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 |
| Environmental Deficiencies |
08/12/2004 |
Make sure that staff members wash their hands when needed. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
08/12/2004 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
08/12/2004 |
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 |
08/12/2004 |
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 |
08/12/2004 |
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 |
| Nutrition and Dietary Deficiencies |
08/12/2004 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
08/12/2004 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
08/12/2004 |
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 |
08/12/2004 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
08/12/2004 |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Pattern |
Potential for minimal harm |
| Resident Rights Deficiencies |
08/12/2004 |
Allow residents to easily see the results of the nursing home's most recent survey. |
Pattern |
Potential for minimal harm |
| Administration Deficiencies |
07/16/2005 |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Pattern |
Actual harm |
| Administration Deficiencies |
07/16/2005 |
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 |
| Administration Deficiencies |
07/16/2005 |
Quickly tell the resident's doctor the results of lab tests. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
07/16/2005 |
Set up or keep a group of people to review and ensure quality. |
Pattern |
Actual harm |
| Environmental Deficiencies |
07/16/2005 |
Provide clean bed and bath linens that are in good condition. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/16/2005 |
Keep sound levels comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/16/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/16/2005 |
Get rid of garbage properly. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
07/16/2005 |
Have a program to keep infection from spreading. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/16/2005 |
Make sure that staff members wash their hands when needed. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/16/2005 |
Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
07/16/2005 |
Protect residents from mistreatment, neglect, and/or theft of personal property. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
07/16/2005 |
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 |
| Nutrition and Dietary Deficiencies |
07/16/2005 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/16/2005 |
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 |
07/16/2005 |
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 |
07/16/2005 |
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 |
| Nutrition and Dietary Deficiencies |
07/16/2005 |
Provide special eating equipment and utensils for each resident who needs them. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/16/2005 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
07/16/2005 |
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 |
07/16/2005 |
Provide drugs and related services needed by each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/16/2005 |
Provide activities to meet the needs of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/16/2005 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/16/2005 |
Give professional services that follow each resident's written care plan. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
07/16/2005 |
Give each resident care and services to get or keep the highest quality of life possible. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/16/2005 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
07/16/2005 |
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
07/16/2005 |
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 |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/16/2005 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/16/2005 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
07/16/2005 |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/16/2005 |
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 |
| Resident Assessment Deficiencies |
07/16/2005 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Isolated |
Actual harm |
| Resident Assessment Deficiencies |
07/16/2005 |
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
07/16/2005 |
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 |
07/16/2005 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/16/2005 |
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 |
07/16/2005 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/16/2005 |
Send and promptly deliver unopened mail to residents. |
Pattern |
Potential for minimal harm |
| Resident Rights Deficiencies |
07/16/2005 |
Have a private telephone available for use. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/16/2005 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/16/2005 |
Make sure that private space is available in the nursing home for resident groups or residents' families to meet. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/16/2005 |
Provide services to meet the needs and preferences of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Smoke Compartmentation and Control Deficiencies |
08/10/2004 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
07/13/2005 |
an approved installation, maintenance and testing program for fire alarm systems. |
Widespread |
Potential for minimal harm |