Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep accurate
|
01/03/2011
|
00/07/2012
|
Some
|
complete and organized clinical records on each re
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure services provided by the nursing facility meet professional standards of quality.
|
01/03/2011
|
00/07/2012
|
2
|
Some
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
01/03/2011
|
00/07/2012
|
2
|
Some
|
Resident Assessment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Develop a complete care plan that meets all the resident's needs
|
01/03/2011
|
00/07/2012
|
Few
|
with timetables and actions that can be measured.
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Immediately tell the resident
|
01/03/2011
|
00/07/2012
|
and a family member of situations (injury/decline/
|
the resident's doctor
|
Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep accurate
|
00/01/2009
|
01/06/2009
|
Few
|
complete and organized clinical records on each re
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly
|
00/01/2009
|
00/00/0000
|
Some
|
and develop corrective plans of action.
|
Mistreatment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
1) Hire only people with no legal history of abusing
|
00/01/2009
|
01/06/2009
|
neglect or mistreatment of residents.
|
neglecting or mistreating residents; or 2) report
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
00/01/2009
|
01/06/2009
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Immediately tell the resident
|
00/01/2009
|
01/06/2009
|
and a family member of situations (injury/decline/
|
the resident's doctor
|
Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
|
02/00/2007
|
02/09/2008
|
2
|
Few
|
|
Keep accurate
|
02/00/2007
|
02/09/2008
|
Few
|
complete and organized clinical records on each re
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
|
02/00/2007
|
02/09/2008
|
3
|
Few
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide care by qualified persons according to each resident's written plan of care.
|
02/00/2007
|
02/09/2008
|
2
|
Few
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
02/00/2007
|
02/09/2008
|
3
|
Few
|
Resident Assessment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Conduct initial and periodic assessments of each resident's functional capacity.
|
02/00/2007
|
02/09/2008
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Immediately tell the resident
|
02/00/2007
|
02/09/2008
|
and a family member of situations (injury/decline/
|
the resident's doctor
|
|
Reasonably accommodate the needs and preferences of each resident.
|
02/00/2007
|
02/09/2008
|
2
|
Few
|
Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Post nurse staffing information/data on a daily basis.
|
02/09/2006
|
00/00/0000
|
1
|
Many
|
|
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident.
|
02/09/2006
|
02/07/2007
|
4
|
Some
|
|
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
|
02/09/2006
|
02/07/2007
|
2
|
Some
|
|
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
|
02/09/2006
|
02/07/2007
|
2
|
Some
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
|
02/09/2006
|
02/01/2009
|
4
|
Some
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide housekeeping and maintenance services.
|
02/09/2006
|
02/01/2009
|
2
|
Some
|
|
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
|
02/09/2006
|
02/07/2007
|
4
|
Some
|
|
Have a program that investigates, controls and keeps infection from spreading.
|
02/09/2006
|
02/07/2007
|
2
|
Some
|
|
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
|
02/09/2006
|
02/07/2007
|
2
|
Few
|
Mistreatment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
1) Hire only people with 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.
|
02/09/2006
|
02/07/2007
|
2
|
Some
|
Nutrition and Dietary Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Store, cook, and serve food in a safe and clean way.
|
02/09/2006
|
02/07/2007
|
2
|
Some
|
Pharmacy Service Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
|
02/09/2006
|
02/07/2007
|
2
|
Few
|
|
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
|
02/09/2006
|
02/07/2007
|
2
|
Few
|
|
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
|
02/09/2006
|
02/07/2007
|
2
|
Few
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide activities to meet the interests and needs of each resident.
|
02/09/2006
|
02/07/2007
|
2
|
Few
|
|
Have enough nurses to care for every resident in a way that maximizes the resident's well being.
|
02/09/2006
|
02/07/2007
|
4
|
Some
|
Resident Assessment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Conduct initial and periodic assessments of each resident's functional capacity.
|
02/09/2006
|
02/07/2007
|
2
|
Few
|
|
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
|
02/09/2006
|
02/07/2007
|
2
|
Few
|
|
Allow residents the right to participate in the planning or revision of care and treatment.
|
02/09/2006
|
02/07/2007
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep residents' personal and medical records private and confidential.
|
02/09/2006
|
02/07/2007
|
2
|
Few
|
|
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
|
02/09/2006
|
02/01/2009
|
2
|
Few
|
Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
|
00/01/2004
|
02/09/2008
|
3
|
Few
|
|
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
|
00/01/2004
|
02/09/2008
|
2
|
Few
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
|
00/01/2004
|
02/01/2004
|
2
|
Some
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
|
00/01/2004
|
02/09/2008
|
3
|
Few
|
Mistreatment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Protect each resident from all abuse, physical punishment, and involuntary separation from others.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
Pharmacy Service Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
|
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide care by qualified persons according to each resident's written plan of care.
|
00/01/2004
|
02/09/2008
|
2
|
Some
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
00/01/2004
|
02/09/2008
|
3
|
Few
|
|
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
|
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
|
Provide or obtain dental services for each resident.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
Resident Assessment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Conduct initial and periodic assessments of each resident's functional capacity.
|
00/01/2004
|
02/09/2008
|
2
|
Some
|
|
Allow residents the right to participate in the planning or revision of care and treatment.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
|
00/01/2004
|
02/09/2008
|
2
|
Few
|
|
Try to resolve each resident's complaints quickly.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
|
Send unopened mail from residents and promptly deliver unopened mail to residents.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
|
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
|
00/01/2004
|
02/01/2004
|
2
|
Few
|
|
Reasonably accommodate the needs and preferences of each resident.
|
00/01/2004
|
02/09/2008
|
2
|
Few
|
Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep accurate
|
00/03/2003
|
00/01/2004
|
Few
|
complete and organized clinical records on each re
|
Pharmacy Service Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
|
00/03/2003
|
00/01/2004
|
2
|
Few
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide care by qualified persons according to each resident's written plan of care.
|
00/03/2003
|
00/01/2004
|
2
|
Few
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
00/03/2003
|
00/01/2004
|
3
|
Few
|
Resident Assessment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Make sure that all required doctor visits are made personally.
|
00/03/2003
|
00/01/2004
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Immediately tell the resident
|
00/03/2003
|
00/01/2004
|
and a family member of situations (injury/decline/
|
the resident's doctor
|