Hammersmith House Nursing Care

Total Number of Beds: 89	Percent of Occupied Beds: 93%
Total Number of Residents: 83	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: 11/24/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.56

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.93

Number of CNA Hours per Nursing Home Resident per Day: 2.09

Number of Staff Hours per Nursing Home Resident per Day: 3.58

Nursing Home Resident Information**:

Percent of Low-Risk Residents Who Have Pressure Sores: 3%
Percent of Short-Stay Residents With Pressure Sores: 22%
Percent of High-Risk Residents Who Have Pressure Sores: 12%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 13%
Percent of Residents Who Have Moderate to Severe Pain: 2%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 30%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 0%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 31%
Percent of Residents Who are More Depressed or Anxious: 10%
Percent of Short-Stay Residents With Delirium: 2%
Percent of Residents Who Were Physically Restrained: 5%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 42%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 5%
Percent of Residents With a Urinary Tract Infection: 3%
** Details Last Reported on: 11/24/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-11-14	2002-02-13	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	Actual harm
2001-11-14	2002-02-13	Mistreatment Deficiencies	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	Resident Rights Deficiencies	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Quality Care Deficiencies	Provide activities to meet the needs of each resident.	Isolated	Actual harm
2001-11-14	2002-02-13	Quality Care Deficiencies	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Actual harm
2001-11-14	2002-02-13	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Actual harm
2001-11-14	2002-02-13	Resident Assessment Deficiencies	Assess the resident when the resident enters the nursing home, in a timely manner.	Isolated	Actual harm
2001-11-14	2002-02-13	Resident Assessment Deficiencies	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Resident Assessment Deficiencies	Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress.	Pattern	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
2001-11-14	2002-02-13	Quality Care Deficiencies	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	Quality Care Deficiencies	Make sure that each resident gets help to keep vision and hearing.	Isolated	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	Quality Care Deficiencies	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Actual harm
2001-11-14	2002-02-13	Quality Care Deficiencies	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Quality Care Deficiencies	Give each resident a special diet to help when there is a nutritional problem.	Isolated	Actual harm
2001-11-14	2002-02-13	Quality Care Deficiencies	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
2001-11-14	2002-02-13	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	Actual harm
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	Nutrition and Dietary Deficiencies	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
2001-11-14	2002-02-06	Pharmacy Service Deficiencies	Provide drugs and related services needed by each resident.	Pattern	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Environmental Deficiencies	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Administration Deficiencies	Get proof that a nurse aide has the training and skills that the State requires.	Isolated	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	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
2001-11-14	2002-02-13	Administration Deficiencies	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Administration Deficiencies	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
2001-11-14	2002-02-13	Administration Deficiencies	Hold committee meetings every 3 months to review and ensure quality in the nursing home.	Pattern	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	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	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	Resident Assessment Deficiencies	Assess the resident when the resident enters the nursing home, in a timely manner.	Pattern	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	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
2002-11-20	2003-01-22	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
2002-11-20	2003-01-22	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Actual harm
2002-11-20	2003-01-22	Resident Assessment Deficiencies	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	Pharmacy Service Deficiencies	Provide drugs and related services needed by each resident.	Isolated	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	Pharmacy Service Deficiencies	Act when the pharmacist reports something unusual.	Isolated	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	Environmental Deficiencies	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	Environmental Deficiencies	Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	Administration Deficiencies	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
2002-11-20	2003-01-22	Administration Deficiencies	Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
2003-11-24	2004-01-12	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
2003-11-24	2004-01-12	Quality Care Deficiencies	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
2003-11-24	2004-01-12	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
2003-11-24	2004-01-12	Environmental Deficiencies	Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
2003-11-24	2004-01-12	Administration Deficiencies	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
2003-11-24	2004-01-12	Administration Deficiencies	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
2003-11-24	2004-01-12	Administration Deficiencies	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm

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