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.
|
00/03/2009
|
00/06/2010
|
2
|
Many
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide housekeeping and maintenance services.
|
00/03/2009
|
00/06/2010
|
2
|
Some
|
|
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
|
00/03/2009
|
00/06/2010
|
2
|
Few
|
|
Have a program that investigates, controls and keeps infection from spreading.
|
00/03/2009
|
00/06/2010
|
2
|
Some
|
|
Make sure that a working call system is available in each resident's room or bathroom and bathing area.
|
00/03/2009
|
00/06/2010
|
4
|
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.
|
00/03/2009
|
00/06/2010
|
2
|
Some
|
|
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
|
00/03/2009
|
00/06/2010
|
2
|
Some
|
Nutrition and Dietary Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
|
00/03/2009
|
00/06/2010
|
2
|
Some
|
|
Store, cook, and serve food in a safe and clean way.
|
00/03/2009
|
00/06/2010
|
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.
|
00/03/2009
|
00/06/2010
|
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.
|
00/03/2009
|
00/06/2010
|
2
|
Few
|
|
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
|
00/03/2009
|
00/06/2010
|
2
|
Some
|
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.
|
00/03/2009
|
00/06/2010
|
2
|
Few
|
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.
|
00/03/2009
|
00/06/2010
|
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.
|
00/03/2009
|
00/06/2010
|
2
|
Few
|
|
Allow residents to easily view the results of the nursing home's most recent inspection.
|
00/03/2009
|
00/06/2010
|
1
|
Some
|
|
Give notice to the resident before a room or roommate change.
|
00/03/2009
|
00/06/2010
|
2
|
Few
|
Administration Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident.
|
01/09/2008
|
01/05/2009
|
3
|
Few
|
|
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
|
01/09/2008
|
01/05/2009
|
2
|
Some
|
|
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
|
01/09/2008
|
00/00/0000
|
2
|
Few
|
|
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident.
|
01/09/2008
|
01/05/2009
|
3
|
Few
|
|
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
|
01/09/2008
|
01/05/2009
|
2
|
Some
|
|
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
|
01/09/2008
|
00/00/0000
|
2
|
Few
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide housekeeping and maintenance services.
|
01/09/2008
|
01/05/2009
|
2
|
Some
|
|
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
|
01/09/2008
|
01/05/2009
|
3
|
Few
|
|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
|
01/09/2008
|
01/05/2009
|
3
|
Few
|
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.
|
01/09/2008
|
01/05/2009
|
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.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
|
01/09/2008
|
01/05/2009
|
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.
|
01/09/2008
|
01/05/2009
|
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.
|
01/09/2008
|
01/05/2009
|
2
|
Some
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
01/09/2008
|
01/05/2009
|
3
|
Few
|
|
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Give each resident enough fluids to keep them healthy and prevent dehydration.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Provide care by qualified persons according to each resident's written plan of care.
|
01/09/2008
|
01/05/2009
|
2
|
Some
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
01/09/2008
|
01/05/2009
|
3
|
Few
|
|
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Give each resident enough fluids to keep them healthy and prevent dehydration.
|
01/09/2008
|
01/05/2009
|
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.
|
01/09/2008
|
01/05/2009
|
3
|
Few
|
|
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
|
01/09/2008
|
00/00/0000
|
1
|
Some
|
|
Allow residents the right to participate in the planning or revision of care and treatment.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Conduct initial and periodic assessments of each resident's functional capacity.
|
01/09/2008
|
01/05/2009
|
3
|
Few
|
|
Allow residents the right to participate in the planning or revision of care and treatment.
|
01/09/2008
|
01/05/2009
|
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.
|
01/09/2008
|
01/05/2009
|
2
|
Some
|
|
Try to resolve each resident's complaints quickly.
|
01/09/2008
|
01/05/2009
|
2
|
Few
|
|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
|
01/09/2008
|
01/05/2009
|
2
|
Some
|
|
Try to resolve each resident's complaints quickly.
|
01/09/2008
|
01/05/2009
|
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.
|
02/07/2007
|
02/07/2007
|
2
|
Few
|
|
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
|
02/07/2007
|
02/08/2009
|
2
|
Few
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide housekeeping and maintenance services.
|
02/07/2007
|
02/07/2007
|
2
|
Some
|
|
Have a program that investigates, controls and keeps infection from spreading.
|
02/07/2007
|
02/07/2007
|
2
|
Few
|
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.
|
02/07/2007
|
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.
|
02/07/2007
|
02/07/2007
|
2
|
Few
|
|
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
|
02/07/2007
|
02/07/2007
|
2
|
Some
|
|
Ensure that residents are safe from serious medication errors.
|
02/07/2007
|
02/07/2007
|
2
|
Some
|
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.
|
02/07/2007
|
02/07/2007
|
2
|
Few
|
|
Provide care by qualified persons according to each resident's written plan of care.
|
02/07/2007
|
02/07/2007
|
2
|
Some
|
|
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves.
|
02/07/2007
|
02/08/2009
|
2
|
Few
|
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.
|
02/07/2007
|
02/07/2007
|
2
|
Few
|
|
Allow residents the right to participate in the planning or revision of care and treatment.
|
02/07/2007
|
02/07/2007
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Try to resolve each resident's complaints quickly.
|
02/07/2007
|
02/07/2007
|
2
|
Few
|
|
Tell the resident or the resident
|
02/07/2007
|
00/00/0000
|
1
|
Many
|
|
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
|
02/07/2007
|
02/07/2007
|
2
|
Few
|
|
Reasonably accommodate the needs and preferences of each resident.
|
02/07/2007
|
02/07/2007
|
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.
|
02/01/2004
|
01/05/2005
|
2
|
Some
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Have a program that investigates, controls and keeps infection from spreading.
|
02/01/2004
|
01/05/2005
|
2
|
Some
|
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.
|
02/01/2004
|
01/05/2005
|
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.
|
02/01/2004
|
01/05/2005
|
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.
|
02/01/2004
|
01/05/2005
|
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.
|
01/08/2004
|
00/02/2006
|
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.
|
01/08/2004
|
00/02/2006
|
1
|
Some
|
|
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
|
01/08/2004
|
00/02/2006
|
1
|
Some
|
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.
|
01/08/2004
|
00/02/2006
|
2
|
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.
|
01/08/2004
|
00/02/2006
|
2
|
Few
|
|
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
|
01/08/2004
|
00/02/2006
|
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.
|
01/08/2004
|
00/02/2006
|
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.
|
00/03/2001
|
00/00/0000
|
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.
|
00/03/2001
|
00/00/0000
|
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.
|
00/03/2001
|
00/00/0000
|
2
|
Few
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
00/03/2001
|
00/00/0000
|
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.
|
00/03/2001
|
00/00/0000
|
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.
|
00/03/2001
|
00/00/0000
|
2
|
Few
|