Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
|
00/02/2008
|
00/04/2009
|
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.
|
00/02/2008
|
00/04/2009
|
2
|
Some
|
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.
|
00/02/2008
|
00/04/2009
|
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.
|
00/02/2008
|
00/04/2009
|
2
|
Few
|
|
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
|
00/02/2008
|
00/04/2009
|
2
|
Some
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide activities to meet the interests and needs of each resident.
|
00/02/2008
|
00/04/2009
|
2
|
Some
|
|
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
|
00/02/2008
|
00/04/2009
|
2
|
Few
|
|
Ensure residents maintain acceptable nutritional status.
|
00/02/2008
|
00/04/2009
|
2
|
Few
|
|
Give each resident enough fluids to keep them healthy and prevent dehydration.
|
00/02/2008
|
00/04/2009
|
2
|
Few
|
|
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
|
00/02/2008
|
00/04/2009
|
2
|
Few
|
|
Give or get specialized rehabilitative services per the patient's assessment or plan of care.
|
00/02/2008
|
00/04/2009
|
2
|
Few
|
Resident Assessment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.
|
00/02/2008
|
00/04/2009
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide residents with private access to a telephone.
|
00/02/2008
|
00/04/2009
|
2
|
Some
|
|
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
|
00/02/2008
|
00/04/2009
|
2
|
Few
|
|
Reasonably accommodate the needs and preferences of each resident.
|
00/02/2008
|
00/04/2009
|
2
|
Few
|
Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
|
02/03/2002
|
02/03/2003
|
2
|
Few
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide housekeeping and maintenance services.
|
02/03/2002
|
02/03/2003
|
2
|
Some
|
|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
|
02/03/2002
|
02/03/2003
|
2
|
Many
|
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.
|
02/03/2002
|
02/03/2003
|
2
|
Few
|
|
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
|
02/03/2002
|
02/03/2003
|
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, with timetables and actions that can be measured.
|
02/03/2002
|
02/03/2003
|
2
|
Some
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure that each resident has the right to join in social, religious, and community activities.
|
02/03/2002
|
02/03/2003
|
2
|
Few
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide medically-related social services to help each resident achieve the highest possible quality of life.
|
01/04/2002
|
01/01/2003
|
2
|
Some
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
01/04/2002
|
01/01/2003
|
2
|
Few
|
|
Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing.
|
01/04/2002
|
01/01/2003
|
2
|
Few
|
|
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
|
01/04/2002
|
01/01/2003
|
2
|
Few
|
|
Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing.
|
01/04/2002
|
01/01/2003
|
2
|
Few
|
Resident Assessment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Allow residents the right to participate in the planning or revision of care and treatment.
|
01/04/2002
|
01/01/2003
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Try to resolve each resident's complaints quickly.
|
01/04/2002
|
01/01/2003
|
2
|
Few
|
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.
|
00/08/2002
|
00/03/2003
|
2
|
Few
|
|
Have a program that investigates, controls and keeps infection from spreading.
|
00/08/2002
|
00/08/2003
|
2
|
Many
|
Nutrition and Dietary Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.
|
00/08/2002
|
00/08/2003
|
2
|
Some
|
|
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
|
00/08/2002
|
00/08/2003
|
2
|
Some
|
|
Store, cook, and serve food in a safe and clean way.
|
00/08/2002
|
00/08/2003
|
2
|
Many
|
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.
|
00/08/2002
|
00/08/2003
|
2
|
Few
|
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.
|
00/08/2002
|
00/08/2003
|
2
|
Some
|
|
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
|
00/08/2002
|
00/08/2003
|
2
|
Few
|
|
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
|
00/08/2002
|
00/08/2003
|
2
|
Some
|
|
Ensure residents maintain acceptable nutritional status.
|
00/08/2002
|
00/08/2003
|
2
|
Few
|
|
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
|
00/08/2002
|
00/08/2003
|
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.
|
00/08/2002
|
00/08/2003
|
2
|
Few
|
Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
|
01/05/2001
|
00/00/0000
|
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.
|
01/05/2001
|
00/00/0000
|
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.
|
01/05/2001
|
00/00/0000
|
2
|
Many
|
Pharmacy Service Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure that residents are safe from serious medication errors.
|
01/05/2001
|
00/00/0000
|
3
|
Few
|
|
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
|
01/05/2001
|
00/00/0000
|
2
|
Some
|
|
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
|
01/05/2001
|
00/00/0000
|
2
|
Many
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide medically-related social services to help each resident achieve the highest possible quality of life.
|
01/05/2001
|
00/00/0000
|
2
|
Few
|
|
Ensure services provided by the nursing facility meet professional standards of quality.
|
01/05/2001
|
00/00/0000
|
2
|
Some
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
01/05/2001
|
00/00/0000
|
3
|
Few
|
|
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
|
01/05/2001
|
00/00/0000
|
3
|
Few
|
|
Ensure residents maintain acceptable nutritional status.
|
01/05/2001
|
00/00/0000
|
3
|
Few
|
|
Give each resident enough fluids to keep them healthy and prevent dehydration.
|
01/05/2001
|
00/00/0000
|
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, with timetables and actions that can be measured.
|
01/05/2001
|
00/00/0000
|
2
|
Few
|