| Date of Violation |
Date Corrected |
Type of Violation |
Deficiency |
Scope |
Level of Harm |
| 2001-09-21 |
2001-11-16 |
Resident Rights Deficiencies |
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Resident Rights Deficiencies |
Keep each resident's personal and medical records private and confidential. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Resident Rights Deficiencies |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Environmental Deficiencies |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
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 |
| 2001-09-21 |
2001-11-16 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Quality Care Deficiencies |
Give professional services that meet a professional standard of quality. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Quality Care Deficiencies |
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Quality Care Deficiencies |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| 2001-09-21 |
2001-11-16 |
Quality Care Deficiencies |
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Environmental Deficiencies |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Quality Care Deficiencies |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| 2001-09-21 |
2001-11-16 |
Quality Care Deficiencies |
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Pharmacy Service Deficiencies |
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
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 |
| 2001-09-21 |
2001-11-16 |
Pharmacy Service Deficiencies |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Quality Care Deficiencies |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
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 |
| 2001-09-21 |
2001-11-16 |
Nutrition and Dietary Deficiencies |
Provide food in a way that meets a resident's needs. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
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 |
Potential for minimal harm |
| 2001-09-21 |
2001-11-16 |
Nutrition and Dietary Deficiencies |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Pharmacy Service Deficiencies |
Provide drugs and related services needed by each resident. |
Pattern |
Potential for minimal harm |
| 2001-09-21 |
2001-11-16 |
Pharmacy Service Deficiencies |
Properly mark drugs and other similar products. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Pharmacy Service Deficiencies |
Keep drugs and other similar products locked safely and properly stored. |
Pattern |
Potential for minimal harm |
| 2001-09-21 |
2001-11-16 |
Environmental Deficiencies |
Have a program to keep infection from spreading. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Environmental Deficiencies |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Administration Deficiencies |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Administration Deficiencies |
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-09-21 |
2001-11-16 |
Administration Deficiencies |
Make sure that nurse aides show they have the skills to be able to care for residents. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-12-11 |
2003-01-09 |
Mistreatment Deficiencies |
Protect residents from mistreatment, neglect, and/or theft of personal property. |
Pattern |
Potential for minimal harm |
| 2002-12-11 |
2003-01-09 |
Resident Rights Deficiencies |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-12-11 |
2003-01-09 |
Resident Assessment Deficiencies |
Assess the resident when the resident enters the nursing home, in a timely manner. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-12-11 |
2003-01-09 |
Resident Assessment Deficiencies |
Check and update (if needed) each resident's assessment every 3 months. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-12-11 |
2003-01-09 |
Quality Care Deficiencies |
Make sure that each resident's nutritional needs were met. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-12-11 |
2003-01-09 |
Pharmacy Service Deficiencies |
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-12-11 |
2003-01-09 |
Pharmacy Service Deficiencies |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-11-06 |
2003-12-11 |
Resident Rights Deficiencies |
Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help. |
Pattern |
Potential for minimal harm |
| 2003-11-06 |
2003-12-11 |
Mistreatment Deficiencies |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Pattern |
Potential for minimal harm |
| 2003-11-06 |
2003-12-11 |
Resident Rights Deficiencies |
Provide care in a way that keeps or builds each resident's dignity and self respect. |
Pattern |
Minimal harm or potential for actual harm |
| 2003-11-06 |
2003-12-11 |
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 |
| 2003-11-06 |
2003-12-11 |
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 |
| 2003-11-06 |
2003-12-11 |
Quality Care Deficiencies |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-11-06 |
2003-12-11 |
Pharmacy Service Deficiencies |
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-11-06 |
2003-12-11 |
Nutrition and Dietary Deficiencies |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Pattern |
Potential for minimal harm |
| 2003-11-06 |
2003-12-11 |
Administration Deficiencies |
Keep accurate and appropriate medical records. |
Pattern |
Potential for minimal harm |
*** All violations listed are based on federal government records.