| Date of Violation |
Date Corrected |
Type of Violation |
Deficiency |
Scope |
Level of Harm |
| 2001-04-24 |
2001-04-24 |
Resident Rights Deficiencies |
Let the resident refuse treatment or refuse to take part in an experiment. |
Isolated |
Actual harm |
| 2001-04-24 |
2001-04-24 |
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 |
| 2001-04-24 |
2001-04-24 |
Resident Rights Deficiencies |
Keep each resident's personal and medical records private and confidential. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Resident Rights Deficiencies |
Protect the resident from a transfer or discharge that is not wanted or needed. |
Isolated |
Actual harm |
| 2001-04-24 |
2001-04-24 |
Resident Rights Deficiencies |
Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Mistreatment Deficiencies |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Actual harm |
| 2001-04-24 |
2001-04-24 |
Resident Rights Deficiencies |
Provide services to meet the needs and preferences of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Quality Care Deficiencies |
Provide activities to meet the needs of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Quality Care Deficiencies |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Environmental Deficiencies |
Keep safe, clean and homelike surroundings. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Environmental Deficiencies |
Keep sound levels comfortable. |
Pattern |
Potential for minimal harm |
| 2001-04-24 |
2001-04-24 |
Resident Assessment Deficiencies |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Widespread |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
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. |
Widespread |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Resident Assessment Deficiencies |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Widespread |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
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 |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Resident Assessment Deficiencies |
Keep assessments completed in the preceding 15 months in the resident's active record. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
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 |
| 2001-04-24 |
2001-04-24 |
Quality Care Deficiencies |
Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
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 |
| 2001-04-24 |
2001-04-24 |
Quality Care Deficiencies |
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Quality Care Deficiencies |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Quality Care Deficiencies |
Make sure that each resident's nutritional needs were met. |
Pattern |
Actual harm |
| 2001-04-24 |
2001-04-24 |
Quality Care Deficiencies |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Widespread |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Nutrition and Dietary Deficiencies |
Hire a qualified dietician. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Nutrition and Dietary Deficiencies |
Provide special eating equipment and utensils for each resident who needs them. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Resident Assessment Deficiencies |
Make sure that doctors visit residents regularly, as required. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Quality Care Deficiencies |
Give or get special rehabilitation if in the patient's plan of care. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Quality Care Deficiencies |
Give special rehabilitation by skilled workers, when ordered by a doctor. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Environmental Deficiencies |
Have a program to keep infection from spreading. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Administration Deficiencies |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Widespread |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
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 |
| 2001-04-24 |
2001-04-24 |
Administration Deficiencies |
Give lab tests only when the attending doctor ordered them. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Administration Deficiencies |
Quickly tell the resident's doctor the results of lab tests. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-04-24 |
2001-04-24 |
Administration Deficiencies |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
Resident Rights Deficiencies |
Give the resident's legal representative the same rights as the resident. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
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 |
| 2002-03-07 |
2002-05-29 |
Mistreatment Deficiencies |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
Mistreatment Deficiencies |
1) Hire only people who have 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. |
Isolated |
Actual harm |
| 2002-03-07 |
2002-07-16 |
Mistreatment Deficiencies |
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Resident Rights Deficiencies |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
Administration Deficiencies |
Hire a qualified activities director. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Quality Care Deficiencies |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Environmental Deficiencies |
Keep safe, clean and homelike surroundings. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Resident Assessment Deficiencies |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
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 |
| 2002-03-07 |
2002-07-16 |
Resident Assessment Deficiencies |
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
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 |
| 2002-03-07 |
2002-07-16 |
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 |
| 2002-03-07 |
2002-05-07 |
Environmental Deficiencies |
Make sure that the nursing home area is free of dangers that cause accidents. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Quality Care Deficiencies |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| 2002-03-07 |
2002-05-29 |
Quality Care Deficiencies |
Give each resident enough fluids to keep them healthy and prevent dehydration. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
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 |
| 2002-03-07 |
2002-05-29 |
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 |
| 2002-03-07 |
2002-07-16 |
Quality Care Deficiencies |
Have enough nurses to care for every resident in a way that maximizes the resident's well being. |
Widespread |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Nutrition and Dietary Deficiencies |
Make sure that the attending doctor orders special diets. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
Quality Care Deficiencies |
Give or get special rehabilitation if in the patient's plan of care. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Pharmacy Service Deficiencies |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
Pharmacy Service Deficiencies |
Keep drugs and other similar products locked safely and properly stored. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
Environmental Deficiencies |
Stop employees, who have a disease that can spread, from having direct contact with residents or food. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Environmental Deficiencies |
Make sure that staff members wash their hands when needed. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
Environmental Deficiencies |
Make sure that the nursing home area is safe, easy to use, clean and comfortable. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Administration Deficiencies |
Be administered in a way that leads to the highest possible level of well being for each resident. |
Widespread |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Administration Deficiencies |
Follow all laws and professional standards. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-07 |
Administration Deficiencies |
Hire nurse aides who have shown that they are skilled and care for residents safely on-the-job. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
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 |
| 2002-03-07 |
2002-07-16 |
Administration Deficiencies |
Get services outside the nursing home that meet professional standards. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
Administration Deficiencies |
Give lab tests only when the attending doctor ordered them. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Administration Deficiencies |
Quickly tell the resident's doctor the results of lab tests. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-07-16 |
Administration Deficiencies |
Keep complete, dated lab records in the resident's file. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-07 |
Administration Deficiencies |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-07 |
Administration Deficiencies |
Have a detailed, written plan for disasters and emergencies. |
Pattern |
Potential for minimal harm |
| 2002-03-07 |
2002-05-07 |
Administration Deficiencies |
Train all employees on what to do in an emergency. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-03-07 |
2002-05-29 |
Administration Deficiencies |
Hold committee meetings every 3 months to review and ensure quality in the nursing home. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-04-15 |
2003-05-16 |
Quality Care Deficiencies |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Pattern |
Minimal harm or potential for actual harm |
| 2003-04-15 |
2003-05-16 |
Environmental Deficiencies |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| 2003-04-15 |
2003-05-16 |
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 |
| 2003-04-15 |
2003-05-16 |
Pharmacy Service Deficiencies |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
*** All violations listed are based on federal government records.