| 5% | Percent of Residents Who Spend Most of Their Time in Bed or in a Chair |
| 4% | Percent of Residents Who Have Moderate to Severe Pain |
| 4% | Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder |
| 0% | Percent of Low-Risk Residents Who Have Pressure Sores |
| 11% | Percent of Residents Whose Need for Help With Daily Activities Has Increased |
| 5% | Percent of Residents With a Urinary Tract Infection |
| 10% | Percent of Short-Stay Residents Who Had Moderate to Severe Pain |
| 4% | Percent of Residents Who Lose Too Much Weight |
| 0% | Percent of Residents Who Were Physically Restrained |
| 16% | Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse |
| 0% | Percent of Short-Stay Residents With Delirium |
| 36% | Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder |
| 16% | Percent of Short-Stay Residents With Pressure Sores |
| 15% | Percent of Residents Who are More Depressed or Anxious |
| 11% | Percent of High-Risk Residents Who Have Pressure Sores |
6
1...12
|
Quality Care: Have enough nurses to care for every resident in a way that maximizes the resident's well being.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Widespread |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
6
1...12
|
Nutrition and Diet: Provide food in a way that meets a resident's needs.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Widespread |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
6
1...12
|
Administration: Hire nurse aides who have completed required training and shown that they are skilled.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Widespread |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
6
1...12
|
Administration: Hire nurse aides who have shown that they are skilled and care for residents safely on-the-job.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Widespread |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
6
1...12
|
Resident Rights: Provide care in a way that keeps or builds each resident's dignity and self respect.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Widespread |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
6
1...12
|
Nutrition and Diet: Make sure that residents are well nourished.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Widespread |
| Survey Date: | 20050505 | Corrected By: | 20050605 |
|
5
1...12
|
Nutrition and Diet: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Pattern |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
5
1...12
|
Pharmacy Service: Act when the pharmacist reports something unusual.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Pattern |
| Survey Date: | 20030228 | Corrected By: | 20030423 |
|
5
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: | Pattern |
| Survey Date: | 20050505 | Corrected By: | 20050605 |
|
5
1...12
|
Quality Care: Provide activities to meet the needs of each resident.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Pattern |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
4
1...12
|
Environmental: Make sure that the nursing home area is free of dangers that cause accidents.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20050505 | Corrected By: | 20050605 |
|
4
1...12
|
Resident Assessment: Check and update (if needed) each resident's assessment every 3 months.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20050505 | Corrected By: | 20050605 |
|
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: | 20050505 | Corrected By: | 20050605 |
|
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: | 20040323 | Corrected By: | 20040421 |
|
4
1...12
|
Environmental: Have a program to keep infection from spreading.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20050505 | Corrected By: | 20050605 |
|
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: | 20050505 | Corrected By: | 20050605 |
|
4
1...12
|
Resident Rights: Provide care in a way that keeps or builds each resident's dignity and self respect.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20030228 | Corrected By: | 20030423 |
|
4
1...12
|
Quality Care: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
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: | 20030228 | Corrected By: | 20030423 |
|
4
1...12
|
Nutrition and Diet: Provide food in a way that meets a resident's needs.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20030228 | Corrected By: | 20030423 |
|
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: | 20040323 | Corrected By: | 20040421 |
|
4
1...12
|
Resident Rights: Let residents complain without being treated differently or badly.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
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: | 20040323 | Corrected By: | 20040421 |
|
4
1...12
|
Environmental: Provide needed housekeeping and maintenance.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
4
1...12
|
Quality Care: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
4
1...12
|
Quality Care: Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
4
1...12
|
Quality Care: 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.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
4
1...12
|
Environmental: Make sure that the nursing home area is free of dangers that cause accidents.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
4
1...12
|
Administration: Get services outside the nursing home that meet professional standards.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20050505 | Corrected By: | 20050605 |
|
3
1...12
|
Administration: Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.
| Level of Harm: | Potential for minimal harm | Scope: | Widespread |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
3
1...12
|
Resident Rights: Have a private telephone available for use.
| Level of Harm: | Potential for minimal harm | Scope: | Widespread |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|
3
1...12
|
Resident Assessment: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.
| Level of Harm: | Potential for minimal harm | Scope: | Widespread |
| Survey Date: | 20040323 | Corrected By: | 20040421 |
|