| 2% | Percent of High-Risk Residents Who Have Pressure Sores |
| 54% | Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder |
| 3% | Percent of Residents Who Lose Too Much Weight |
| 2% | Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder |
| 8% | Percent of Residents Who are More Depressed or Anxious |
| 9% | Percent of Residents Whose Need for Help With Daily Activities Has Increased |
| 4% | Percent of Residents Who Spend Most of Their Time in Bed or in a Chair |
| 0% | Percent of Short-Stay Residents With Delirium |
| 6% | Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse |
| 4% | Percent of Low-Risk Residents Who Have Pressure Sores |
| 8% | Percent of Residents With a Urinary Tract Infection |
| 11% | Percent of Short-Stay Residents Who Had Moderate to Severe Pain |
| 3% | Percent of Residents Who Have Moderate to Severe Pain |
| 14% | Percent of Short-Stay Residents With Pressure Sores |
| 9% | Percent of Residents Who Were Physically Restrained |
12
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: | Immediate jeopardy to resident health or safety | Scope: | Widespread |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
12
1...12
|
Administration: Be administered in a way that leads to the highest possible level of well being for each resident.
| Level of Harm: | Immediate jeopardy to resident health or safety | Scope: | Widespread |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
8
1...12
|
Quality Care: Give each resident care and services to get or keep the highest quality of life possible.
| Level of Harm: | Actual harm | Scope: | Pattern |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
5
1...12
|
Pharmacy Service: Provide drugs and related services needed by each resident.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Pattern |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
5
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: | Pattern |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
5
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: | Pattern |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
5
1...12
|
Environmental: Make sure that staff members wash their hands when needed.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Pattern |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
5
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: | Pattern |
| Survey Date: | 20050413 | Corrected By: | 20050420 |
|
5
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: | Pattern |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
5
1...12
|
Environmental: Keep sound levels comfortable.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Pattern |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
5
1...12
|
Environmental: Provide needed housekeeping and maintenance.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Pattern |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
5
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: | Pattern |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
5
1...12
|
Environmental: Provide needed housekeeping and maintenance.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Pattern |
| Survey Date: | 20050413 | Corrected By: | 20050513 |
|
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: | 20040402 | Corrected By: | 20040423 |
|
4
1...12
|
Pharmacy Service: Provide drugs and related services needed by each resident.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20050413 | Corrected By: | 20050425 |
|
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: | 20050413 | Corrected By: | 20050513 |
|
4
1...12
|
Pharmacy Service: Keep drugs and other similar products locked safely and properly stored.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20050413 | Corrected By: | 20050414 |
|
4
1...12
|
Administration: Give or get lab tests to meet the needs of residents.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20050413 | Corrected By: | 20050501 |
|
4
1...12
|
Administration: Set up or keep a group of people to review and ensure quality.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20050413 | Corrected By: | 20050501 |
|
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: | 20060518 | Corrected By: | 20060608 |
|
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: | 20060518 | Corrected By: | 20060608 |
|
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: | 20050413 | Corrected By: | 20050422 |
|
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: | 20050413 | Corrected By: | 20050513 |
|
4
1...12
|
Mistreatment: Keep each resident free from physical restraints, unless needed for medical treatment.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
4
1...12
|
Resident Assessment: Keep assessments completed in the preceding 15 months in the resident's active record.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
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: | 20040402 | Corrected By: | 20040423 |
|
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: | 20040402 | Corrected By: | 20040423 |
|
4
1...12
|
Quality Care: Give each resident enough fluids to keep them healthy and prevent dehydration.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
4
1...12
|
Nutrition and Diet: Make sure that the attending doctor orders special diets.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Isolated |
| Survey Date: | 20040402 | Corrected By: | 20040423 |
|
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: | 20060518 | Corrected By: | 20060526 |
|
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: | 20050413 | Corrected By: | 20050513 |
|
3
1...12
|
Resident Rights: Allow residents to easily see the results of the nursing home's most recent survey.
| Level of Harm: | Potential for minimal harm | Scope: | Widespread |
| Survey Date: | 20040402 | Corrected By: | |
|