Governor Winthrop Nursing Home

Total Number of Beds: 91	Percent of Occupied Beds: 95%
Total Number of Residents: 86	Located Within a Hospital: No
Type of Ownership: For profit - Corporation	Multiple Nursing Homes by Same Owner: Yes
Councils the Nursing Home Participates in: Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 08/13/2002

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.25

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.73

Number of CNA Hours per Nursing Home Resident per Day: 1.92

Number of Staff Hours per Nursing Home Resident per Day: 2.9

Nursing Home Resident Information**:

Percent of Short-Stay Residents With Pressure Sores: 13%
Percent of High-Risk Residents Who Have Pressure Sores: 9%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 22%
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: 6%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 6%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 15%
Percent of Residents Who are More Depressed or Anxious: 12%
Percent of Short-Stay Residents With Delirium: 0%
Percent of Residents Who Were Physically Restrained: 5%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 66%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 3%
Percent of Residents With a Urinary Tract Infection: 6%
** Details Last Reported on: 8/13/2002

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2000-09-20	2000-10-30	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
2000-09-20	2000-11-01	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Potential for minimal harm
2000-09-20	2000-11-01	Nutrition and Dietary Deficiencies	Provide a tasty and well-balanced diet that meets the nutritional needs of each resident.	Isolated	Minimal harm or potential for actual harm
2000-09-20	2000-11-01	Nutrition and Dietary Deficiencies	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
2000-09-20	2000-11-01	Administration Deficiencies	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
2000-09-20	2000-11-01	Administration Deficiencies	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
2000-09-20	2000-10-30	Administration Deficiencies	Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
2000-09-20	2000-11-01	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
2001-09-21	2001-12-10	Resident Rights Deficiencies	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
2001-09-21	2001-12-10	Mistreatment Deficiencies	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
2001-09-21	2001-12-10	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
2001-09-21	2001-12-10	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
2001-09-21	2001-12-10	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
2001-09-21	2002-02-22	Environmental Deficiencies	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
2001-09-21	2001-12-10	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
2001-09-21	2001-12-10	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
2001-09-21	2001-12-10	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
2001-09-21	2001-12-10	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	2001-12-10	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
2001-09-21	2001-12-10	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2001-09-21	2001-12-10	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
2001-09-21	2001-12-10	Environmental Deficiencies	Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection.	Pattern	Minimal harm or potential for actual harm
2001-09-21	2001-12-10	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
2001-09-21	2001-12-10	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
2001-09-21	2001-12-10	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
2002-08-13	2002-10-21	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
2002-08-13	2002-10-21	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
2002-08-13	2002-10-21	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
2002-08-13	2002-10-21	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
2002-08-13	2002-10-21	Resident Assessment Deficiencies	Do an assessment of the resident every year.	Pattern	Minimal harm or potential for actual harm
2002-08-13	2002-10-21	Resident Assessment Deficiencies	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Minimal harm or potential for actual harm
2002-08-13	2002-10-21	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
2002-08-13	2002-10-21	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
2002-08-13	2002-10-21	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
2002-08-13	2002-10-21	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
2002-08-13	2002-10-21	Resident Assessment Deficiencies	Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress.	Widespread	Minimal harm or potential for actual harm
2002-08-13	2002-10-21	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
2002-08-13	2002-10-21	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
2002-08-13	2002-10-21	Environmental Deficiencies	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
2002-08-13	2002-10-21	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
2002-08-13	2002-10-21	Administration Deficiencies	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
2002-08-13	2002-10-21	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.