| 14% | Percent of Residents Who Lose Too Much Weight |
| 50% | Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder |
| 14% | Percent of High-Risk Residents Who Have Pressure Sores |
| 20% | Percent of Short-Stay Residents With Pressure Sores |
| 0% | Percent of Short-Stay Residents With Delirium |
| 4% | Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder |
| 0% | Percent of Residents Who Were Physically Restrained |
| 2% | Percent of Residents Who Spend Most of Their Time in Bed or in a Chair |
| 10% | Percent of Short-Stay Residents Who Had Moderate to Severe Pain |
| 5% | Percent of Residents Who Have Moderate to Severe Pain |
| 11% | Percent of Residents Who are More Depressed or Anxious |
| 10% | Percent of Residents Whose Need for Help With Daily Activities Has Increased |
| 11% | Percent of Residents With a Urinary Tract Infection |
| 11% | Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse |
| 0% | Percent of Low-Risk Residents Who Have Pressure Sores |
6
1...12
|
Pharmacy Service: Properly mark drugs and other similar products.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Widespread |
| Survey Date: | 20031023 | Corrected By: | 20031205 |
|
5
1...12
|
Environmental: Make sure that the nursing home area is safe, easy to use, clean and comfortable.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Pattern |
| Survey Date: | 20031023 | Corrected By: | 20031205 |
|
4
1...12
|
Resident Assessment: Make a complete assessment that covers all questions for areas that are listed in official regulations.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20020828 | Corrected By: | 20021010 |
|
4
1...12
|
Environmental: Make sure that staff members wash their hands when needed.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20041211 | Corrected By: | 20050125 |
|
4
1...12
|
Pharmacy Service: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20041211 | Corrected By: | 20050125 |
|
4
1...12
|
Resident Assessment: Do a new assessment after any major change in a resident's physical or mental health.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20041211 | Corrected By: | 20050125 |
|
4
1...12
|
Resident Rights: Provide services to meet the needs and preferences of each resident.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20041211 | Corrected By: | 20050125 |
|
4
1...12
|
Resident Rights: Keep each resident's personal and medical records private and confidential.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20041211 | Corrected By: | 20050125 |
|
4
1...12
|
Pharmacy Service: Make sure that the pharmacist reports anything unusual to the doctor on duty and the director of nursing.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20031023 | Corrected By: | 20031205 |
|
4
1...12
|
Pharmacy Service: Make sure that residents who have not taken antipsychotic drugs are not given these drugs, unless they are used to treat a problem that is diagnosed and noted in the medical record.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20031023 | Corrected By: | 20031205 |
|
4
1...12
|
Quality Care: Give each resident care and services to get or keep the highest quality of life possible.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20031023 | Corrected By: | 20031205 |
|
4
1...12
|
Resident Assessment: Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20031023 | Corrected By: | 20031205 |
|
4
1...12
|
Mistreatment: 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.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20031023 | Corrected By: | 20031205 |
|
4
1...12
|
Environmental: Make sure that staff members wash their hands when needed.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20020828 | Corrected By: | 20021010 |
|
4
1...12
|
Resident Assessment: 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.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20020828 | Corrected By: | 20021010 |
|
4
1...12
|
Environmental: Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20041211 | Corrected By: | 20050125 |
|
3
1...12
|
Mistreatment: Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.
| Level of Harm: | Potential for minimal harm | Scope: | Widespread |
| Survey Date: | 20031023 | Corrected By: | 20031205 |
|
2
1...12
|
Resident Assessment: Keep assessments completed in the preceding 15 months in the resident's active record.
| Level of Harm: | Potential for minimal harm | Scope: | Pattern |
| Survey Date: | 20031023 | Corrected By: | 20031205 |
|