| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
03/19/2004 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/19/2004 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
03/19/2004 |
Set up or keep a group of people to review and ensure quality. |
Widespread |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/19/2004 |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/19/2004 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/19/2004 |
Have a program to keep infection from spreading. |
Widespread |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
03/19/2004 |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
03/19/2004 |
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 |
03/19/2004 |
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 |
03/19/2004 |
Make sure that residents are well nourished. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
03/19/2004 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
03/19/2004 |
Keep drugs and other similar products locked safely and properly stored. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/19/2004 |
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 |
03/19/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/19/2004 |
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 |
| Quality Care Deficiencies |
03/19/2004 |
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/19/2004 |
Check and update (if needed) each resident's assessment every 3 months. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
03/19/2004 |
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 |
| Resident Rights Deficiencies |
03/19/2004 |
Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/19/2004 |
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 |
| Resident Rights Deficiencies |
03/19/2004 |
Allow residents to easily see the results of the nursing home's most recent survey. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/19/2004 |
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 |
03/19/2004 |
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 |
03/19/2004 |
Listen to the resident or family groups or act on their complaints or suggestions. |
Pattern |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
01/21/2005 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/21/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Actual harm |
| Mistreatment Deficiencies |
01/21/2005 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| Mistreatment Deficiencies |
01/21/2005 |
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 |
01/21/2005 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
01/21/2005 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/21/2005 |
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 |
01/21/2005 |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Isolated |
Actual harm |
| Resident Assessment Deficiencies |
01/21/2005 |
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 |
01/21/2005 |
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 Rights Deficiencies |
01/21/2005 |
Have a private telephone available for use. |
Pattern |
Potential for minimal harm |
| Administration Deficiencies |
02/20/2006 |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Isolated |
Immediate jeopardy to resident health or safety |
| Administration Deficiencies |
02/20/2006 |
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 |
02/20/2006 |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
02/20/2006 |
Choose a doctor to be the medical director. |
Isolated |
Immediate jeopardy to resident health or safety |
| Administration Deficiencies |
02/20/2006 |
Help the resident go to and from x-rays and other tests. |
Isolated |
Minimal harm or potential for actual harm |
| Administration Deficiencies |
02/20/2006 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/20/2006 |
Keep safe, clean and homelike surroundings. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/20/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Actual harm |
| Environmental Deficiencies |
02/20/2006 |
Get rid of garbage properly. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/20/2006 |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/20/2006 |
Make sure that staff members wash their hands when needed. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
02/20/2006 |
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 |
02/20/2006 |
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 |
02/20/2006 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
02/20/2006 |
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 |
02/20/2006 |
Make sure that the attending doctor orders special diets. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
02/20/2006 |
Store, cook, and give out food in a safe and clean way. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
02/20/2006 |
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 |
02/20/2006 |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/20/2006 |
Give professional services that follow each resident's written care plan. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/20/2006 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
02/20/2006 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
02/20/2006 |
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 |
02/20/2006 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Immediate jeopardy to resident health or safety |
| Quality Care Deficiencies |
02/20/2006 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
02/20/2006 |
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 |
02/20/2006 |
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 Assessment Deficiencies |
02/20/2006 |
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 |
| Resident Rights Deficiencies |
02/20/2006 |
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 |
02/20/2006 |
Provide proof that all residents' personal money which is deposited with the nursing home, is secure. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
02/20/2006 |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/20/2006 |
Allow residents to easily see the results of the nursing home's most recent survey. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
02/20/2006 |
Have a private telephone available for use. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/20/2006 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
02/20/2006 |
Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Automatic Sprinkler Systems Deficiencies |
03/17/2004 |
an approved automatic sprinkler system connected to the fire alarm system. |
Widespread |
Potential for minimal harm |
| Corridor Walls and Doors Deficiencies |
03/17/2004 |
corridor and hallway doors that block smoke. |
Widespread |
Potential for minimal harm |
| Hazardous Area Deficiencies |
03/17/2004 |
construction that can resist fire for one hour or an approved fire extinguishing system. |
Widespread |
Potential for minimal harm |
| Smoke Compartmentation and Control Deficiencies |
03/17/2004 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Widespread |
Potential for minimal harm |
| Automatic Sprinkler Systems Deficiencies |
01/19/2005 |
an approved automatic sprinkler system connected to the fire alarm system. |
Widespread |
Potential for minimal harm |
| Corridor Walls and Doors Deficiencies |
02/16/2006 |
corridor and hallway doors that block smoke. |
Pattern |
Minimal harm or potential for actual harm |
| Furnishings and Decorations Deficiencies |
02/16/2006 |
restrictions on the use of flammable curtains. |
Widespread |
Minimal harm or potential for actual harm |
| Smoke Compartmentation and Control Deficiencies |
02/16/2006 |
smoke barrier doors that can resist smoke for at least 20 minutes. |
Isolated |
Minimal harm or potential for actual harm |