Beverly Healthcare - Windermere

Total Number of Beds: 120	Percent of Occupied Beds: 91%
Total Number of Residents: 109	Located Within a Hospital: No
Type of Ownership: For profit - Corporation	Multiple Nursing Homes by Same Owner: Yes
Councils the Nursing Home Participates in: Family & Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 07/10/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.27

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.94

Number of CNA Hours per Nursing Home Resident per Day: 2.24

Number of Staff Hours per Nursing Home Resident per Day: 3.45

Nursing Home Resident Information**:

Percent of Short-Stay Residents With Pressure Sores: 22%
Percent of High-Risk Residents Who Have Pressure Sores: 19%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 16%
Percent of Residents Who Have Moderate to Severe Pain: 10%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 23%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 11%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 19%
Percent of Residents Who are More Depressed or Anxious: 9%
Percent of Short-Stay Residents With Delirium: 0%
Percent of Residents Who Were Physically Restrained: 8%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 47%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 10%
Percent of Residents With a Urinary Tract Infection: 7%
** Details Last Reported on: 7/10/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-07-11	2001-08-25	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2001-07-11	2001-08-25	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
2001-07-11	2001-09-26	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
2001-07-11	2001-08-25	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
2001-07-11	2001-08-25	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Actual harm
2001-07-11	2001-08-25	Quality Care Deficiencies	Give each resident a special diet to help when there is a nutritional problem.	Isolated	Minimal harm or potential for actual harm
2001-07-11	2001-08-25	Pharmacy Service Deficiencies	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
2001-07-11	2001-09-26	Nutrition and Dietary Deficiencies	Make sure that residents are well nourished.	Pattern	Potential for minimal harm
2001-07-11	2001-08-25	Nutrition and Dietary Deficiencies	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
2001-07-11	2001-08-25	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2001-07-11	2001-08-25	Environmental Deficiencies	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Mistreatment Deficiencies	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
2002-08-28	2002-10-12	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Pharmacy Service Deficiencies	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Quality Care Deficiencies	Give or get emergency care by a doctor 24 hours a day.	Isolated	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Pharmacy Service Deficiencies	Act when the pharmacist reports something unusual.	Isolated	Minimal harm or potential for actual harm
2002-08-28	2002-10-12	Administration Deficiencies	Hold committee meetings every 3 months to review and ensure quality in the nursing home.	Widespread	Potential for minimal harm
2003-07-10	2003-08-24	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Mistreatment Deficiencies	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Actual harm
2003-07-10	2003-08-24	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Actual harm
2003-07-10	2003-08-24	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Potential for minimal harm
2003-07-10	2003-08-24	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
2003-07-10	2003-08-24	Nutrition and Dietary Deficiencies	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Nutrition and Dietary Deficiencies	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Nutrition and Dietary Deficiencies	Offer other nutritional food to each resident who will not eat the food served.	Isolated	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Nutrition and Dietary Deficiencies	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Nutrition and Dietary Deficiencies	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Widespread	Minimal harm or potential for actual harm
2003-07-10	2003-08-24	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.