| Date of Violation |
Date Corrected |
Type of Violation |
Deficiency |
Scope |
Level of Harm |
| 2001-02-16 |
2001-05-04 |
Resident Rights Deficiencies |
Give the resident's legal representative the same rights as the resident. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
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 |
| 2001-02-16 |
2001-05-04 |
Resident Rights Deficiencies |
Have a private telephone available for use. |
Widespread |
Potential for minimal harm |
| 2001-02-16 |
2001-06-08 |
Mistreatment Deficiencies |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Mistreatment Deficiencies |
Protect each resident from all abuse, physical punishment, and being separated from others. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
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 |
| 2001-02-16 |
2001-05-04 |
Resident Rights Deficiencies |
Provide services to meet the needs and preferences of each resident. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
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 |
| 2001-02-16 |
2001-06-08 |
Environmental Deficiencies |
Provide needed housekeeping and maintenance. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Resident Assessment Deficiencies |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Resident Assessment Deficiencies |
Do a new assessment after any major change in a resident's physical or mental health. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Resident Assessment Deficiencies |
Check and update (if needed) each resident's assessment every 3 months. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-06-08 |
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 |
| 2001-02-16 |
2001-06-08 |
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 |
| 2001-02-16 |
2001-05-04 |
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 |
| 2001-02-16 |
2001-05-04 |
Resident Assessment Deficiencies |
Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Quality Care Deficiencies |
Give each resident care and services to get or keep the highest quality of life possible. |
Isolated |
Actual harm |
| 2001-02-16 |
2001-05-04 |
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 |
| 2001-02-16 |
2001-05-04 |
Quality Care Deficiencies |
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. |
Isolated |
Actual harm |
| 2001-02-16 |
2001-05-04 |
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 |
| 2001-02-16 |
2001-05-04 |
Quality Care Deficiencies |
Give the right treatment and services to residents who have mental or social problems adjusting. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Environmental Deficiencies |
Make sure that the nursing home area is free of dangers that cause accidents. |
Widespread |
Potential for minimal harm |
| 2001-02-16 |
2001-06-08 |
Quality Care Deficiencies |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| 2001-02-16 |
2001-05-04 |
Quality Care Deficiencies |
Make sure that each resident's nutritional needs were met. |
Isolated |
Actual harm |
| 2001-02-16 |
2001-05-04 |
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 |
| 2001-02-16 |
2001-05-04 |
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 |
| 2001-02-16 |
2001-05-04 |
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 |
| 2001-02-16 |
2001-05-04 |
Nutrition and Dietary Deficiencies |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. |
Widespread |
Potential for minimal harm |
| 2001-02-16 |
2001-05-04 |
Nutrition and Dietary Deficiencies |
Provide food in a way that meets a resident's needs. |
Pattern |
Potential for minimal harm |
| 2001-02-16 |
2001-05-04 |
Nutrition and Dietary Deficiencies |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Potential for minimal harm |
| 2001-02-16 |
2001-05-04 |
Environmental Deficiencies |
Get rid of garbage properly. |
Widespread |
Potential for minimal harm |
| 2001-02-16 |
2001-05-04 |
Pharmacy Service Deficiencies |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Environmental Deficiencies |
Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection. |
Widespread |
Potential for minimal harm |
| 2001-02-16 |
2001-05-04 |
Environmental Deficiencies |
Keep all essential equipment working safely. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Environmental Deficiencies |
Make sure that a working call system is available in each resident's room or bathroom and bathing area. |
Isolated |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Administration Deficiencies |
1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator. |
Widespread |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Administration Deficiencies |
Keep accurate and appropriate medical records. |
Pattern |
Minimal harm or potential for actual harm |
| 2001-02-16 |
2001-05-04 |
Administration Deficiencies |
Train all employees on what to do in an emergency. |
Pattern |
Potential for minimal harm |
| 2002-02-19 |
2002-04-04 |
Resident Rights Deficiencies |
Give the resident's legal representative the same rights as the resident. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Resident Rights Deficiencies |
Let the resident refuse treatment or refuse to take part in an experiment. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Resident Rights Deficiencies |
Try to resolve each resident's complaints quickly. |
Pattern |
Potential for minimal harm |
| 2002-02-19 |
2002-04-04 |
Resident Rights Deficiencies |
Allow residents to easily see the results of the nursing home's most recent survey. |
Widespread |
Potential for minimal harm |
| 2002-02-19 |
2002-04-04 |
Resident Rights Deficiencies |
Let residents give themselves their drugs if they are able. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Mistreatment Deficiencies |
Keep each resident free from physical restraints, unless needed for medical treatment. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Resident Rights Deficiencies |
Provide services to meet the needs and preferences of each resident. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Quality Care Deficiencies |
Provide social services for related medical problems to help each resident achieve the highest possible quality of life. |
Widespread |
Potential for minimal harm |
| 2002-02-19 |
2002-04-04 |
Environmental Deficiencies |
Keep safe, clean and homelike surroundings. |
Pattern |
Potential for minimal harm |
| 2002-02-19 |
2002-04-04 |
Environmental Deficiencies |
Provide needed housekeeping and maintenance. |
Pattern |
Potential for minimal harm |
| 2002-02-19 |
2002-04-04 |
Environmental Deficiencies |
Keep sound levels comfortable. |
Pattern |
Potential for minimal harm |
| 2002-02-19 |
2002-04-04 |
Resident Assessment Deficiencies |
Make a complete assessment that covers all questions for areas that are listed in official regulations. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Resident Assessment Deficiencies |
Do a new assessment after any major change in a resident's physical or mental health. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Quality Care Deficiencies |
Give professional services that follow each resident's written care plan. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Quality Care Deficiencies |
Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Quality Care Deficiencies |
Make sure that each resident gets help to keep vision and hearing. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Quality Care Deficiencies |
Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Environmental Deficiencies |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Potential for minimal harm |
| 2002-02-19 |
2002-04-04 |
Quality Care Deficiencies |
Make sure that each resident's nutritional needs were met. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Pharmacy Service Deficiencies |
Make sure that residents are safe from serious medication errors. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Nutrition and Dietary Deficiencies |
Hire a qualified dietician. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Nutrition and Dietary Deficiencies |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Environmental Deficiencies |
Get rid of garbage properly. |
Widespread |
Potential for minimal harm |
| 2002-02-19 |
2002-04-04 |
Pharmacy Service Deficiencies |
Provide drugs and related services needed by each resident. |
Widespread |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Pharmacy Service Deficiencies |
Use the services of a licensed pharmacist. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Pharmacy Service Deficiencies |
Keep drugs and other similar products locked safely and properly stored. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Environmental Deficiencies |
Have a program to keep infection from spreading. |
Widespread |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Environmental Deficiencies |
Keep all essential equipment working safely. |
Widespread |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
Administration Deficiencies |
1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator. |
Pattern |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Administration Deficiencies |
1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides. |
Isolated |
Minimal harm or potential for actual harm |
| 2002-02-19 |
2002-04-04 |
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 |
| 2002-02-19 |
2002-04-04 |
Administration Deficiencies |
Keep accurate and appropriate medical records. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
Resident Rights Deficiencies |
Give the resident's legal representative the same rights as the resident. |
Pattern |
Potential for minimal harm |
| 2003-05-27 |
2003-08-20 |
Resident Rights Deficiencies |
Let the resident refuse treatment or refuse to take part in an experiment. |
Pattern |
Potential for minimal harm |
| 2003-05-27 |
2003-08-20 |
Resident Rights Deficiencies |
Let residents give themselves their drugs if they are able. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
Resident Rights Deficiencies |
Make sure that each resident has the right to join in social, religious, and community activities. |
Pattern |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
Environmental Deficiencies |
Provide needed housekeeping and maintenance. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
Environmental Deficiencies |
Keep sound levels comfortable. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
Quality Care Deficiencies |
Make sure that each resident gets help to keep vision and hearing. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
Environmental Deficiencies |
Make sure that the nursing home area is free of dangers that cause accidents. |
Pattern |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
Quality Care Deficiencies |
Make sure each resident is being watched and has assistance devices when needed, to prevent accidents. |
Isolated |
Actual harm |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
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 |
| 2003-05-27 |
2003-08-20 |
Nutrition and Dietary Deficiencies |
Make sure that residents are well nourished. |
Pattern |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
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. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
Nutrition and Dietary Deficiencies |
Store, cook, and give out food in a safe and clean way. |
Widespread |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
Quality Care Deficiencies |
Give or get special rehabilitation if in the patient's plan of care. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
Pharmacy Service Deficiencies |
Provide drugs and related services needed by each resident. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
Pharmacy Service Deficiencies |
Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing. |
Isolated |
Minimal harm or potential for actual harm |
| 2003-05-27 |
2003-08-20 |
Environmental Deficiencies |
Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public. |
Widespread |
Potential for minimal harm |
*** All violations listed are based on federal government records.