| Percent of High Risk Long Term Nursing Home Residents Who Have Pressure Sores: 16% |
| Percent of Long Term Nursing Home Residents Given Influenza Vaccination During the Flu Season: 72% |
| Percent of Long Term Nursing Home Residents Who are More Depressed or Anxious: 7% |
| Percent of Long Term Nursing Home Residents Who Have Moderate to Severe Pain: 2% |
| Percent of Long Term Nursing Home Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 5% |
| Percent of Long Term Nursing Home Residents Who Lose Too Much Weight: 5% |
| Percent of Long Term Nursing Home Residents Who Spend Most of Their Time in Bed or in a Chair: 6% |
| Percent of Long Term Nursing Home Residents Who Were Assessed and Given Pneumococcal Vaccination: 70% |
| Percent of Long Term Nursing Home Residents Who Were Physically Restrained: 10% |
| Percent of Long Term Nursing Home Residents Whose Ability to Move About in and Around Their Room Got Worse: 5% |
| Percent of Long Term Nursing Home Residents Whose Need for Help With Daily Activities Has Increased: 19% |
| Percent of Long Term Nursing Home Residents With a Urinary Tract Infection: 12% |
| Percent of Low-Risk Long Term Nursing Home Residents Who Have Pressure Sores: 2% |
| Percent of Low-Risk Long Term Nursing Home Residents Who Lose Control of Their Bowels or Bladder: 32% |
| Percent of Short Term Nursing Home Residents Given Influenza Vaccination During the Flu Season: 53% |
| Percent of Short Term Nursing Home Residents Who Had Moderate to Severe Pain: 8% |
| Percent of Short Term Nursing Home Residents Who Were Assessed and Given Pneumococcal Vaccination: 29% |
| Percent of Short Term Nursing Home Residents With Delirium: 0% |
| Percent of Short Term Nursing Home Residents With Pressure Sores: 20% |
Nursing Home Violations by Pilgrim Manor Guest Care Center LCC
|
| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
11/09/2004 |
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 |
| Administration Deficiencies |
11/09/2004 |
Give or get lab tests to meet the needs of residents. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
11/09/2004 |
Give or get x-rays and other tests to meet the needs of residents. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
11/09/2004 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/09/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/09/2004 |
Have enough outside airflow. |
Pattern |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
11/09/2004 |
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 |
| Nutrition and Dietary Deficiencies |
11/09/2004 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
11/09/2004 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Immediate jeopardy to resident health or safety |
| Pharmacy Service Deficiencies |
11/09/2004 |
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 |
| Pharmacy Service Deficiencies |
11/09/2004 |
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 |
11/09/2004 |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
11/09/2004 |
Act when the pharmacist reports something unusual. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/09/2004 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/09/2004 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/09/2004 |
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 |
11/09/2004 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
11/09/2004 |
Make sure that doctors visit residents regularly, as required. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
11/09/2004 |
Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States. |
Pattern |
Potential for minimal harm |
| Resident Rights Deficiencies |
11/09/2004 |
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 |
| Resident Rights Deficiencies |
11/09/2004 |
Listen to the resident or family groups or act on their complaints or suggestions. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
11/09/2004 |
Provide services to meet the needs and preferences of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
11/03/2005 |
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 |
11/03/2005 |
Set up or keep a group of people to review and ensure quality. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/03/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/03/2005 |
Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
11/03/2005 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
11/03/2005 |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
11/03/2005 |
Act when the pharmacist reports something unusual. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/03/2005 |
Give professional services that follow each resident's written care plan. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
11/03/2005 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
11/03/2005 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
11/03/2005 |
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 |
11/03/2005 |
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: |