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St. Francis Care/brackenville
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100 St. Claire Drive
Hockessin, DE 19707
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Details
| Type of Ownership | For profit - Corporation |
| Participates in Medicare? | Yes |
| Participates in Medicaid? | Yes |
| Certified Beds | 104 |
| Continuing Care? | No |
| Resident Council? | Yes |
| Family Council? | Yes |
| Multi-Home Chain? | No |
| Located in a Hospital? | No |
| Special Focus Facility? | No |
View: Health Inspections | Quality Measures | Staffing | Fire Inspections
Health Inspections
Most Recent Inspection: 11/07/2011
| Date of last standard health inspection: | 11/07/2011 |
| Quality Indicator Survey | No |
| Dates of Complaint Investigations: | 12/01/2010 - 11/30/2011 |
| Total number of Health Deficiencies for this nursing home: | 30 |
| Average number of Health Deficiencies in DE: | 13 |
| Average number of Health Deficiencies in US: | 8 |
| Range of Health Deficiencies in DE: | 0 - 30 |
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Set up or keep a group of people to review and ensure quality. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Pattern |
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Provide needed housekeeping and maintenance. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Pattern |
| Make sure that the nursing home area is free of dangers that cause accidents. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Pattern |
| Keep all essential equipment working safely. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Pattern |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
Nutrition and Dietary Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Store, cook, and give out food in a safe and clean way. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Widespread |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Provide activities to meet the needs of each resident. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
| Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
| Develop/implement required procedures for the administration of immunizations. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
| Give or get dental care for each resident. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
Resident Assessment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
Resident Rights Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help. | 11/07/2011 | 01/25/2012 | Potential for minimal harm | Pattern |
| Provide care in a way that keeps or builds each resident's dignity and self respect. | 11/07/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Pattern |
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep accurate and appropriate medical records. | 10/26/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Have a program to keep infection from spreading. | 10/26/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Pattern |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | 10/26/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
Resident Assessment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Assess the resident when the resident enters the nursing home, in a timely manner. | 10/26/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
| Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. | 10/26/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
Resident Rights Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 10/26/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
| Provide services to meet the needs and preferences of each resident. | 10/26/2011 | 01/25/2012 | Minimal harm or potential for actual harm | Isolated |
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Make sure that nurse aides show they have the skills to be able to care for residents. | 05/13/2011 | 07/26/2011 | Minimal harm or potential for actual harm | Isolated |
| Keep accurate and appropriate medical records. | 05/13/2011 | 09/14/2011 | Minimal harm or potential for actual harm | Isolated |
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Make sure that the nursing home area is free of dangers that cause accidents. | 05/13/2011 | 09/14/2011 | Actual harm | Isolated |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 05/13/2011 | 07/26/2011 | Minimal harm or potential for actual harm | Isolated |
Pharmacy Service Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Make sure that residents are safe from serious medication errors. | 05/13/2011 | 07/26/2011 | Minimal harm or potential for actual harm | Isolated |
| Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | 05/13/2011 | 07/26/2011 | Minimal harm or potential for actual harm | Isolated |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give professional services that meet a professional standard of quality. | 05/13/2011 | 07/26/2011 | Minimal harm or potential for actual harm | Isolated |
| Give each resident care and services to get or keep the highest quality of life possible. | 05/13/2011 | 09/14/2011 | Minimal harm or potential for actual harm | Isolated |
Resident Assessment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 05/13/2011 | 09/14/2011 | Minimal harm or potential for actual harm | Isolated |
Resident Rights Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 05/13/2011 | 09/14/2011 | Minimal harm or potential for actual harm | Isolated |
Inspection, 10/28/2010
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Choose a doctor to be the medical director. | 10/28/2010 | 12/27/2010 | Minimal harm or potential for actual harm | Pattern |
| Keep accurate and appropriate medical records. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
| Set up or keep a group of people to review and ensure quality. | 10/28/2010 | 12/27/2010 | Minimal harm or potential for actual harm | Pattern |
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Have a program to keep infection from spreading. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Protect each resident from all abuse, physical punishment, and being separated from others. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
| 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. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
Pharmacy Service Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Pattern |
| Make sure that residents are safe from serious medication errors. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Pattern |
| Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | 10/28/2010 | 03/25/2011 | Minimal harm or potential for actual harm | Pattern |
| At least once a month, have a licensed pharmacist check the drugs that each resident takes. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give professional services that meet a professional standard of quality. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
| Give each resident care and services to get or keep the highest quality of life possible. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
| Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Pattern |
Resident Assessment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
Resident Rights Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
| Provide care in a way that keeps or builds each resident's dignity and self respect. | 10/28/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
Inspection, 10/22/2010
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give each resident care and services to get or keep the highest quality of life possible. | 10/22/2010 | 02/25/2011 | Immediate jeopardy to resident health or safety | Pattern |
Inspection, 09/24/2010
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep accurate and appropriate medical records. | 09/24/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Have a program to keep infection from spreading. | 09/24/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give professional services that meet a professional standard of quality. | 09/24/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
| Give each resident care and services to get or keep the highest quality of life possible. | 09/24/2010 | 02/25/2011 | Minimal harm or potential for actual harm | Isolated |
Inspection, 06/15/2010
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| post nurse staffing information. | 06/15/2010 | 08/17/2010 | Potential for minimal harm | Pattern |
| Train all employees on what to do in an emergency. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Pattern |
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep accurate and appropriate medical records. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Provide needed housekeeping and maintenance. | 06/15/2010 | 08/17/2010 | Potential for minimal harm | Pattern |
| Make sure that the nursing home area is free of dangers that cause accidents. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Pattern |
| Get rid of garbage properly. | 06/15/2010 | 08/17/2010 | Potential for minimal harm | Pattern |
| Have a program to keep infection from spreading. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Widespread |
| Keep all essential equipment working safely. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Pattern |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable. | 06/15/2010 | 08/17/2010 | Potential for minimal harm | Pattern |
| Have enough outside airflow. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Pattern |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
Nutrition and Dietary Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Provide food in a way that meets a resident's needs. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| Store, cook, and give out food in a safe and clean way. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Pattern |
Pharmacy Service Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Pattern |
| Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| At least once a month, have a licensed pharmacist check the drugs that each resident takes. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give each resident care and services to get or keep the highest quality of life possible. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
Resident Assessment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Make a complete assessment that covers all questions for areas that are listed in official regulations. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Pattern |
Resident Assessment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Pattern |
Resident Rights Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| Keep each resident's personal and medical records private and confidential. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| Have a private telephone available for use. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Isolated |
| Provide care in a way that keeps or builds each resident's dignity and self respect. | 06/15/2010 | 08/17/2010 | Minimal harm or potential for actual harm | Pattern |
Inspection, 03/24/2010
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep accurate and appropriate medical records. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Pattern |
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Provide needed housekeeping and maintenance. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
| Make sure that the nursing home area is free of dangers that cause accidents. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
| Have a program to keep infection from spreading. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
Pharmacy Service Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give each resident care and services to get or keep the highest quality of life possible. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
| Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
| Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
Resident Assessment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
Resident Rights Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
| Provide services to meet the needs and preferences of each resident. | 03/24/2010 | 05/04/2010 | Minimal harm or potential for actual harm | Isolated |
Inspection, 03/30/2009
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep accurate and appropriate medical records. | 03/30/2009 | 06/24/2009 | Minimal harm or potential for actual harm | Isolated |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep each resident free from physical restraints, unless needed for medical treatment. | 03/30/2009 | 06/24/2009 | Actual harm | Isolated |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give professional services that meet a professional standard of quality. | 03/30/2009 | 06/24/2009 | Minimal harm or potential for actual harm | Isolated |
| Give each resident care and services to get or keep the highest quality of life possible. | 03/30/2009 | 06/24/2009 | Actual harm | Isolated |
Resident Assessment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | 03/30/2009 | 06/24/2009 | Minimal harm or potential for actual harm | Isolated |
| 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. | 03/30/2009 | 06/24/2009 | Minimal harm or potential for actual harm | Isolated |
Inspection, 01/12/2009
Administration Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Pattern |
| Get services outside the nursing home that meet professional standards. | 01/12/2009 | 03/10/2009 | Potential for minimal harm | Widespread |
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Make sure that the nursing home area is free of dangers that cause accidents. | 01/12/2009 | 03/10/2009 | Potential for minimal harm | Pattern |
| Get rid of garbage properly. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Widespread |
| Have a program to keep infection from spreading. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Widespread |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable. | 01/12/2009 | 03/10/2009 | Potential for minimal harm | Pattern |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Pattern |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep each resident free from physical restraints, unless needed for medical treatment. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Isolated |
| 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. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Pattern |
Nutrition and Dietary Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Store, cook, and give out food in a safe and clean way. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Widespread |
Pharmacy Service Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Make sure that residents are safe from serious medication errors. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Pattern |
Pharmacy Service Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Isolated |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Develop/implement required procedures for the administration of immunizations. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Isolated |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give professional services that meet a professional standard of quality. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Isolated |
| Give each resident care and services to get or keep the highest quality of life possible. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Pattern |
| Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Isolated |
Resident Assessment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Assess the resident when the resident enters the nursing home, in a timely manner. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Isolated |
| 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. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Isolated |
Resident Rights Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Allow residents to easily see the results of the nursing home's most recent survey. | 01/12/2009 | 03/10/2009 | Potential for minimal harm | Widespread |
| Provide care in a way that keeps or builds each resident's dignity and self respect. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Pattern |
| Provide services to meet the needs and preferences of each resident. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Isolated |
Resident Rights Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 01/12/2009 | 03/10/2009 | Minimal harm or potential for actual harm | Isolated |
Nursing Home Staffing
Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.
| National Average | Average in DE | Golden Living Center, Asheville | |
| RN Staff Only1 | N/A | N/A | 5 out of 5 stars |
| Total Number of Residents | 86 | 90 | 79 |
|
Total, Licensed Nurse Staff Hours per Resident per Day |
1 hour 29 minutes | 1 hour 53 minutes | 1 hour 57 minutes |
|
RN Hours per Resident per Day |
40 minutes | 1 hour | 1 hour 10 minutes |
|
LPN/LVN Hours per Resident per Day |
49 minutes | 52 minutes | 46 minutes |
|
CNA Hours per Resident per Day |
2 hours 25 minutes | 2 hours 33 minutes | 2 hours 24 minutes |
1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.
Quality Measures
Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.
Long-Term Residents
| Percent of high-risk long-stay residents who have pressure sores | 15% |
| Percent of long-stay residents given influenza vaccination during the flu season | 88% |
| Percent of long-stay residents who are more depressed or anxious | 4% |
| Percent of long-stay residents who had a urinary tract infection | 12% |
| Percent of long-stay residents who have moderate to severe pain | 3% |
| Percent of long-stay residents who have/had a catheter inserted and left in their bladder | 2% |
| Percent of long-stay residents who spend most of their time in bed or in a chair | 3% |
| Percent of long-stay residents who were assessed and given pneumococcal vaccination | 85% |
| Percent of long-stay residents who were physically restrained | 1% |
| Percent of long-stay residents whose ability to move about in and around their room got worse | 19% |
| Percent of long-stay residents whose need for help with daily activities has increased | 16% |
| Percent of low-risk long-stay residents who have pressure sores | 0% |
| Percent of low-risk long-stay residents who lose control of their bowels or bladder | 44% |
Short-Term Residents
| Percent of long-stay residents who lose too much weight | 12% |
| Percent of short-stay residents given influenza vaccination during the flu season | 75% |
| Percent of short-stay residents who had moderate to severe pain | 23% |
| Percent of short-stay residents who have delirium | 0% |
| Percent of short-stay residents who have pressure sores | 15% |
| Percent of short-stay residents who were assessed and given pneumococcal vaccination | 71% |
Fire Safety Inspections
Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.
Most Recent Inspection: 11/07/2011
| Automatic Sprinkler Systems in all required areas | fully sprinklered |
| Date of last standard fire safety inspection: | 11/07/2011 |
| Dates of Complaint Investigations: | 12/01/2010 - 11/30/2011 |
| Total number of Fire Safety Deficiencies for this nursing home: | 0 |
| Average number of Fire Safety Deficiencies in DE: | 4 |
| Average number of Fire Safety Deficiencies in US: | 4 |
| Range of Fire Safety Deficiencies in DE: | 0 - 7 |
Inspection, 01/14/2009
Hazardous Area Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| construction that can resist fire for one hour or an approved fire extinguishing system. | 01/14/2009 | 03/10/2009 | Potential for minimal harm | Widespread |
Vertical Openings Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors. | 01/14/2009 | 03/10/2009 | Potential for minimal harm | Pattern |
