| Health Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Administration Deficiencies |
04/29/2004 |
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 |
04/29/2004 |
Have a detailed, written plan for disasters and emergencies. |
Widespread |
Potential for minimal harm |
| Administration Deficiencies |
04/29/2004 |
Train all employees on what to do in an emergency. |
Widespread |
Potential for minimal harm |
| Administration Deficiencies |
04/29/2004 |
Set up or keep a group of people to review and ensure quality. |
Widespread |
Potential for minimal harm |
| Environmental Deficiencies |
04/29/2004 |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
04/29/2004 |
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 |
| Environmental Deficiencies |
04/29/2004 |
Make sure that a working call system is available in each resident's room or bathroom and bathing area. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
04/29/2004 |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
04/29/2004 |
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 |
04/29/2004 |
Store, cook, and give out food in a safe and clean way. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
04/29/2004 |
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 |
04/29/2004 |
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 |
04/29/2004 |
Keep drugs and other similar products locked safely and properly stored. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/29/2004 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/29/2004 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/29/2004 |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
04/29/2004 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
04/29/2004 |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| Quality Care Deficiencies |
04/29/2004 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Actual harm |
| Resident Assessment Deficiencies |
04/29/2004 |
Do a new assessment after any major change in a resident's physical or mental health. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
04/29/2004 |
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 |
04/29/2004 |
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 Assessment Deficiencies |
04/29/2004 |
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 |
04/29/2004 |
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 |
| Administration Deficiencies |
03/14/2005 |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Pattern |
Immediate jeopardy to resident health or safety |
| Administration Deficiencies |
03/14/2005 |
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 |
| Administration Deficiencies |
03/14/2005 |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/14/2005 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
03/14/2005 |
Keep all essential equipment working safely. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
03/14/2005 |
Store, cook, and give out food in a safe and clean way. |
Isolated |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
03/14/2005 |
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 |
03/14/2005 |
At least once a month, have a licensed pharmacist check the drugs that each resident takes. |
Pattern |
Minimal harm or potential for actual harm |
| Pharmacy Service Deficiencies |
03/14/2005 |
Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/14/2005 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/14/2005 |
Give professional services that follow each resident's written care plan. |
Pattern |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
03/14/2005 |
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 |
03/14/2005 |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Immediate jeopardy to resident health or safety |
| Resident Assessment Deficiencies |
03/14/2005 |
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. |
Isolated |
Immediate jeopardy to resident health or safety |
| Resident Rights Deficiencies |
03/14/2005 |
Bill properly: Charged resident for items that Medicare or Medicaid pays for. |
Pattern |
Minimal harm or potential for actual harm |
| Resident Rights Deficiencies |
03/14/2005 |
Allow residents to easily see the results of the nursing home's most recent survey. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
03/14/2005 |
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 |
01/27/2006 |
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 |
01/27/2006 |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/27/2006 |
Provide needed housekeeping and maintenance. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/27/2006 |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/27/2006 |
Get rid of garbage properly. |
Pattern |
Minimal harm or potential for actual harm |
| Environmental Deficiencies |
01/27/2006 |
Provide at least one room to use as a dining room and for activities, that is a good size, with good lighting, airflow and furniture. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
01/27/2006 |
Make sure that residents are well nourished. |
Isolated |
Minimal harm or potential for actual harm |
| Nutrition and Dietary Deficiencies |
01/27/2006 |
Make sure that the attending doctor orders special diets. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/27/2006 |
Give professional services that meet a professional standard of quality. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/27/2006 |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| Quality Care Deficiencies |
01/27/2006 |
Make sure that each resident's nutritional needs were met. |
Isolated |
Minimal harm or potential for actual harm |
| Resident Assessment Deficiencies |
01/27/2006 |
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 |
01/27/2006 |
Provide proof that all residents' personal money which is deposited with the nursing home, is secure. |
Widespread |
Potential for minimal harm |
| Resident Rights Deficiencies |
01/27/2006 |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Isolated |
Minimal harm or potential for actual harm |
| Fire Safety Violations: |
| Category: |
Date: |
Specific Violation: |
Scope: |
Level of Harm Caused: |
| Corridor Walls and Doors Deficiencies |
04/28/2004 |
corridor and hallway doors that block smoke. |
Widespread |
Potential for minimal harm |
| Miscellaneous Deficiencies |
04/28/2004 |
fire safety features required by current fire safety codes. |
Widespread |
Potential for minimal harm |
| Smoking Regulations Deficiencies |
04/28/2004 |
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed. |
Widespread |
Potential for minimal harm |
| Automatic Sprinkler Systems Deficiencies |
03/10/2005 |
automatic sprinkler systems that have been maintained in working order. |
Isolated |
Minimal harm or potential for actual harm |
| Emergency Plans and Fire Drills Deficiencies |
03/10/2005 |
record of quarterly fire drills for each shift under varying conditions. |
Widespread |
Potential for minimal harm |