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.
|
01/06/2012
|
01/01/2001
|
2
|
Some
|
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.
|
01/06/2012
|
01/01/2001
|
2
|
Few
|
|
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
|
01/06/2012
|
01/01/2001
|
4
|
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.
|
01/06/2012
|
01/01/2001
|
2
|
Few
|
|
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
|
01/06/2012
|
01/01/2001
|
2
|
Some
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
|
01/06/2012
|
01/01/2001
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep residents' personal and medical records private and confidential.
|
01/06/2012
|
01/01/2001
|
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.
|
02/08/2011
|
02/03/2012
|
2
|
Some
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
|
02/08/2011
|
02/03/2012
|
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.
|
02/06/2011
|
02/09/2012
|
2
|
Some
|
|
Quickly tell the resident's doctor the results of laboratory tests.
|
02/06/2011
|
02/09/2012
|
2
|
Few
|
|
Keep clinical record information safe.
|
02/06/2011
|
02/09/2012
|
1
|
Some
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
|
02/06/2011
|
00/00/0000
|
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.
|
02/06/2011
|
02/09/2012
|
2
|
Few
|
|
Have a program that investigates, controls and keeps infection from spreading.
|
02/06/2011
|
02/09/2012
|
2
|
Many
|
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.
|
02/06/2011
|
02/09/2012
|
4
|
Few
|
|
Protect each resident from mistreatment, neglect and misappropriation of personal property.
|
02/06/2011
|
02/09/2012
|
2
|
Some
|
|
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.
|
02/06/2011
|
02/09/2012
|
2
|
Few
|
|
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.
|
02/06/2011
|
02/09/2012
|
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.
|
02/06/2011
|
02/09/2012
|
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.
|
02/06/2011
|
02/09/2012
|
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.
|
02/06/2011
|
02/09/2012
|
2
|
Few
|
|
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
|
02/06/2011
|
02/09/2012
|
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.
|
02/06/2011
|
02/09/2012
|
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.
|
02/06/2011
|
02/09/2012
|
2
|
Few
|
|
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
|
02/06/2011
|
02/09/2012
|
2
|
Few
|
|
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.
|
02/06/2011
|
02/09/2012
|
2
|
Few
|
Resident Rights Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Keep residents' personal and medical records private and confidential.
|
02/06/2011
|
02/09/2012
|
2
|
Some
|
|
Try to resolve each resident's complaints quickly.
|
02/06/2011
|
02/09/2012
|
2
|
Few
|
|
Let residents talk to and get information from agencies acting on their behalf.
|
02/06/2011
|
02/09/2012
|
1
|
Many
|
|
Reasonably accommodate the needs and preferences of each resident.
|
02/06/2011
|
02/09/2012
|
2
|
Few
|
Quality Care Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
|
01/08/2006
|
01/06/2007
|
2
|
Few
|
Resident Assessment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Make sure that doctors visit residents regularly, as required.
|
01/08/2006
|
02/02/2006
|
2
|
Some
|
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.
|
02/05/2004
|
00/01/2006
|
2
|
Many
|
|
Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility.
|
02/05/2004
|
00/01/2006
|
2
|
Many
|
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.
|
02/05/2004
|
00/01/2006
|
4
|
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.
|
02/05/2004
|
00/01/2006
|
3
|
Few
|
|
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.
|
02/05/2004
|
00/01/2006
|
2
|
Some
|
Pharmacy Service Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Ensure that residents are safe from serious medication errors.
|
02/05/2004
|
01/06/2007
|
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.
|
02/05/2004
|
01/06/2007
|
2
|
Many
|
Resident Assessment Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor.
|
02/05/2004
|
00/01/2006
|
2
|
Some
|
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.
|
02/05/2004
|
00/01/2006
|
2
|
Some
|
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.
|
02/00/2001
|
01/06/2002
|
2
|
Some
|
|
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
|
02/00/2001
|
01/06/2002
|
2
|
Some
|
|
Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility.
|
02/00/2001
|
01/06/2002
|
2
|
Some
|
|
Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.
|
02/00/2001
|
01/06/2002
|
2
|
Few
|
|
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
|
02/00/2001
|
01/06/2002
|
2
|
Some
|
Environmental Deficiencies
|
|
Deficiency
|
Inspection Date
|
Correction Date
|
Level of Harm
|
Residents Affected
|
|
Provide housekeeping and maintenance services.
|
02/00/2001
|
01/06/2002
|
2
|
Some
|
|
Have a program that investigates, controls and keeps infection from spreading.
|
02/00/2001
|
00/03/2004
|
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%.
|
02/00/2001
|
01/06/2002
|
2
|
Few
|
|
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
|
02/00/2001
|
01/06/2002
|
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.
|
02/00/2001
|
01/06/2002
|
3
|
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.
|
02/00/2001
|
01/06/2002
|
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.
|
02/00/2001
|
01/06/2002
|
2
|
Few
|
|
Have enough nurses to care for every resident in a way that maximizes the resident's well being.
|
02/00/2001
|
01/06/2002
|
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.
|
02/00/2001
|
00/03/2004
|
2
|
Some
|
|
Assess in a timely manner the resident when the resident enters the nursing home.
|
02/00/2001
|
00/03/2004
|
2
|
Few
|
|
Assure that each resident
|
02/00/2001
|
00/03/2004
|
2
|
Few
|
|
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
|
02/00/2001
|
00/03/2004
|
2
|
Few
|
|
Allow residents the right to participate in the planning or revision of care and treatment.
|
02/00/2001
|
01/06/2002
|
2
|
Few
|