| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
06/17/2004 |
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. |
Pattern |
Potential for minimal harm |
| Administration Deficiencies |
06/17/2004 |
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 |
06/17/2004 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
06/17/2004 |
Provide needed housekeeping and maintenance. |
Pattern |
Potential for minimal harm |
| Pharmacy Service Deficiencies |
06/17/2004 |
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 |
06/17/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/17/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
06/17/2004 |
Give each resident care and services to get or keep the highest quality of life possible. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/17/2004 |
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 |
06/17/2004 |
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
06/17/2004 |
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 Rights Deficiencies |
06/17/2004 |
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 |
| Administration Deficiencies |
05/26/2005 |
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 |
05/26/2005 |
Give or get lab tests to meet the needs of residents. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
05/26/2005 |
Give lab tests only when the attending doctor ordered them. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
05/26/2005 |
Keep temperature levels comfortable and safe. |
Pattern |
Potential for minimal harm |
| Environmental Deficiencies |
05/26/2005 |
Have a program to keep infection from spreading. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
05/26/2005 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
05/26/2005 |
Make sure there is a program to prevent/deal with mice, insects, or other pests. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
05/26/2005 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
05/26/2005 |
Provide drugs and related services needed by each resident. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
05/26/2005 |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/26/2005 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
05/26/2005 |
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
05/26/2005 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
05/26/2005 |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Isolated |
Actual harm |
| Resident Rights Deficiencies |
05/26/2005 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
07/13/2006 |
post nurse staffing information. |
Widespread |
Potential for minimal harm |
| Administration Deficiencies |
07/13/2006 |
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 |
07/13/2006 |
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 |
07/13/2006 |
Give or get lab tests to meet the needs of residents. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
07/13/2006 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/13/2006 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/13/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/13/2006 |
Get rid of garbage properly. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/13/2006 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
07/13/2006 |
Have enough backup water supply for important areas of the nursing home. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
07/13/2006 |
Make sure there is a program to prevent/deal with mice, insects, or other pests. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/13/2006 |
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 |
07/13/2006 |
Provide food in a way that meets a resident's needs. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
07/13/2006 |
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 |
| Pharmacy Service Deficiencies |
07/13/2006 |
Provide drugs and related services needed by each resident. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
07/13/2006 |
Act when the pharmacist reports something unusual. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
07/13/2006 |
Give professional services that follow each resident's written care plan. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
07/13/2006 |
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 Rights Deficiencies |
07/13/2006 |
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 |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/13/2006 |
Have a private telephone available for use. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
07/13/2006 |
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: |
| Corridor Walls and Doors Deficiencies |
06/16/2004 |
corridor and hallway doors that block smoke. |
Pattern |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
06/16/2004 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Widespread |
Minimal harm or potential for actual harm |
| Fire Alarm Systems Deficiencies |
05/24/2005 |
properly maintained smoke detectors. |
Isolated |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
07/11/2006 |
at least two compartments on every floor to protect residents from smoke. |
Isolated |
Minimal harm or potential for actual harm |