| 100% | Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 97% | Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine |
| 91% | Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 72% | Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine |
| 35% | Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 29% | Percent of long-stay residents who received an antipsychotic medication |
| 21% | Percent of long-stay residents whose need for help with daily activities has increased |
| 18% | Percent of long-stay residents who lose too much weight |
| 15% | Percent of long-stay high-risk residents with pressure ulcers |
| 13% | Percent of long-stay residents who have depressive symptoms |
| 10% | Percent of short-stay residents who self-report moderate to severe pain |
| 7% | Percent of long-stay residents who have/had a catheter inserted and left in their bladder. |
| 7% | Percent of long-stay residents with a urinary tract infection |
| 5% | Percent of long-stay residents experiencing one or more falls with major injury |
| 5% | Percent of short-stay residents who newly received an antipsychotic medication |
| 5% | Percent of long-stay residents who self-report moderate to severe pain. |
| 1% | Percent of long-stay residents who were physically restrained |
| 0% | Percent of short-stay residents with Pressure ulcers that are new or worsened |
Building Construction: a two-hour-resistant firewall in common walls.
| Level of Harm: | Potential for minimal harm | Scope: | Many |
| Survey Date: | 1/12/11 | Corrected By: | 2/1/11 |
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Pharmacy Service: 1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being.
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 3/25/10 | Corrected By: | 6/9/10 |
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Administration: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 2/10/12 | Corrected By: | 3/9/12 |
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Administration: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 3/25/10 | Corrected By: | 6/9/10 |
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Smoke Compartmentation and Control: walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 1/12/11 | Corrected By: | 2/1/11 |
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Pharmacy Service: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 2/10/12 | Corrected By: | 3/9/12 |
|
Quality Care : Have enough nurses to care for every resident in a way that maximizes the resident's well being.
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 2/10/12 | Corrected By: | 3/9/12 |
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Resident Rights: Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Some |
| Survey Date: | 1/13/11 | Corrected By: | NA |
|
Resident Assessment: Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 1/13/11 | Corrected By: | 2/27/11 |
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Smoke Compartmentation and Control: proper construction of ducts through walls designed to prevent smoke passage.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 1/12/11 | Corrected By: | 2/1/11 |
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Quality Care : Provide care by qualified persons according to each resident's written plan of care.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 3/25/10 | Corrected By: | 6/9/10 |
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Quality Care : Provide care by qualified persons according to each resident's written plan of care.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 2/10/12 | Corrected By: | 3/9/12 |
|
Quality Care : Provide necessary care and services to maintain the highest well being of each resident .
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 2/10/12 | Corrected By: | 3/9/12 |
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Administration: Quickly tell the resident's doctor the results of lab tests.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 1/13/11 | Corrected By: | 2/27/11 |
|
Resident Rights: Reasonably accommodate the needs and preferences of each resident.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 2/10/12 | Corrected By: | 3/9/12 |
|
Resident Assessment: Allow the resident the right to participate in the planning or revision of the resident's care plan.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 1/13/11 | Corrected By: | 2/27/11 |
|
Resident Assessment: Allow the resident the right to participate in the planning or revision of the resident's care plan.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 3/25/10 | Corrected By: | 5/6/10 |
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Smoking Regulations: posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 2/9/12 | Corrected By: | 2/28/12 |
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Smoking Regulations: posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 3/24/10 | Corrected By: | 5/19/10 |
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Environmental: Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 3/25/10 | Corrected By: | 5/6/10 |
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Exits and Egress: corridors or aisles that are unobstructed and are at least 8 feet in width.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 3/24/10 | Corrected By: | 5/19/10 |
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Hazardous Area: construction that can resist fire for one hour or an approved fire extinguishing system.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 2/9/12 | Corrected By: | 2/29/12 |
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Pharmacy Service: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 3/25/10 | Corrected By: | 5/6/10 |
|
Resident Assessment: Conduct initial and periodic assessments of each resident's functional capacity.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 3/25/10 | Corrected By: | 6/9/10 |
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Resident Rights: Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 2/10/12 | Corrected By: | 3/9/12 |
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Automatic Sprinkler Systems: an approved automatic sprinkler system connected to the fire alarm system.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 2/9/12 | Corrected By: | 2/10/12 |
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Quality Care : Make sure that residents receive proper treatment and assistive devices to maintain their vision and hearing.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 2/10/12 | Corrected By: | 3/9/12 |
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Quality Care : Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 3/25/10 | Corrected By: | 5/6/10 |
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Quality Care : Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 3/25/10 | Corrected By: | 6/9/10 |
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