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.
|
02/03/2009
|
02/04/2010
|
2
|
Few
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
|
02/03/2009
|
02/04/2010
|
2
|
Few
|
|
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
|
02/03/2009
|
02/04/2010
|
4
|
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.
|
02/03/2009
|
02/04/2010
|
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.
|
00/02/2009
|
01/07/2012
|
2
|
Few
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
|
00/02/2009
|
01/07/2012
|
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.
|
00/02/2009
|
01/07/2012
|
2
|
Some
|
|
Dispose of garbage and refuse properly.
|
00/02/2009
|
02/08/2009
|
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.
|
00/02/2009
|
01/07/2012
|
2
|
Some
|
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.
|
00/05/2008
|
01/07/2012
|
2
|
Few
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
|
00/05/2008
|
01/07/2012
|
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.
|
00/05/2008
|
01/07/2012
|
2
|
Few
|
Mistreatment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep each resident free from physical restraints, unless needed for medical treatment.
|
00/05/2008
|
01/09/2009
|
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.
|
00/05/2008
|
01/07/2012
|
2
|
Few
|
|
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
|
00/05/2008
|
01/09/2009
|
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.
|
00/05/2008
|
01/09/2009
|
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.
|
00/05/2008
|
01/07/2012
|
2
|
Few
|
|
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
|
00/05/2008
|
01/07/2012
|
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.
|
02/03/2007
|
01/02/2009
|
4
|
Some
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
|
02/03/2007
|
01/02/2009
|
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.
|
02/03/2007
|
01/02/2009
|
2
|
Few
|
Pharmacy Service Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure that residents are safe from serious medication errors.
|
02/03/2007
|
01/02/2009
|
4
|
Some
|
|
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
|
02/03/2007
|
01/02/2009
|
4
|
Some
|
|
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
|
02/03/2007
|
01/02/2009
|
4
|
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.
|
02/03/2007
|
01/02/2009
|
4
|
Some
|
|
Provide necessary care and services to maintain or improve the highest well being of each resident.
|
02/03/2007
|
01/02/2009
|
4
|
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.
|
02/03/2007
|
01/02/2009
|
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.
|
01/03/2004
|
02/00/2005
|
2
|
Some
|
|
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
|
01/03/2004
|
00/00/0000
|
2
|
Some
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
|
01/03/2004
|
02/00/2005
|
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.
|
01/03/2004
|
02/00/2005
|
2
|
Few
|
Mistreatment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep each resident free from physical restraints, unless needed for medical treatment.
|
01/03/2004
|
02/00/2005
|
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.
|
01/03/2004
|
02/00/2005
|
2
|
Some
|
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%.
|
01/03/2004
|
02/00/2005
|
2
|
Some
|
|
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
|
01/03/2004
|
02/00/2005
|
2
|
Some
|
|
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
|
01/03/2004
|
02/00/2005
|
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.
|
01/03/2004
|
02/00/2005
|
2
|
Some
|
|
Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing.
|
01/03/2004
|
02/00/2005
|
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.
|
01/03/2004
|
02/00/2005
|
2
|
Some
|
|
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
|
01/03/2004
|
02/00/2005
|
2
|
Some
|
|
Allow residents the right to participate in the planning or revision of care and treatment.
|
01/03/2004
|
02/00/2005
|
2
|
Some
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Give residents a notice of rights, rules, services and charges.
|
01/03/2004
|
00/00/0000
|
1
|
Some
|
|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
|
01/03/2004
|
00/00/0000
|
2
|
Few
|
|
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
|
01/03/2004
|
02/00/2005
|
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.
|
00/04/2003
|
01/08/2004
|
3
|
Few
|
|
Have a program that investigates, controls and keeps infection from spreading.
|
00/04/2003
|
01/08/2004
|
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.
|
00/04/2003
|
01/08/2004
|
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.
|
00/04/2003
|
01/08/2004
|
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.
|
00/04/2003
|
01/08/2004
|
2
|
Few
|
|
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
|
00/04/2003
|
01/08/2004
|
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.
|
00/04/2003
|
00/00/0000
|
2
|
Few
|
|
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
|
00/04/2003
|
01/08/2004
|
2
|
Few
|
|
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
|
00/04/2003
|
01/08/2004
|
2
|
Few
|
|
Ensure residents maintain acceptable nutritional status.
|
00/04/2003
|
01/08/2004
|
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.
|
00/04/2003
|
01/08/2004
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
|
00/04/2003
|
01/08/2004
|
2
|
Few
|
|
Listen to the resident groups and act on their complaints and suggestions that affect resident care and life.
|
00/04/2003
|
00/00/0000
|
2
|
Some
|
|
Reasonably accommodate the needs and preferences of each resident.
|
00/04/2003
|
01/08/2004
|
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.
|
01/00/2002
|
02/03/2004
|
2
|
Some
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide housekeeping and maintenance services.
|
01/00/2002
|
02/03/2004
|
2
|
Some
|
|
Dispose of garbage and refuse properly.
|
01/00/2002
|
02/06/2003
|
2
|
Few
|
|
Have a program that investigates, controls and keeps infection from spreading.
|
01/00/2002
|
02/06/2003
|
2
|
Some
|
|
Put firmly secured handrails on each side of hallways.
|
01/00/2002
|
02/06/2003
|
2
|
Some
|
Mistreatment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
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.
|
01/00/2002
|
02/06/2003
|
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.
|
01/00/2002
|
02/06/2003
|
2
|
Few
|
|
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
|
01/00/2002
|
02/06/2003
|
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.
|
01/00/2002
|
02/06/2003
|
2
|
Some
|
|
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
|
01/00/2002
|
02/06/2003
|
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.
|
01/00/2002
|
02/06/2003
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep residents' personal and medical records private and confidential.
|
01/00/2002
|
02/06/2003
|
2
|
Few
|
|
Allow residents to easily view the results of the nursing home's most recent inspection.
|
01/00/2002
|
02/03/2004
|
1
|
Some
|
|
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
|
01/00/2002
|
02/06/2003
|
2
|
Few
|