| 99% | Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine |
| 96% | Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 91% | Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 90% | Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine |
| 43% | Percent of short-stay residents who self-report moderate to severe pain |
| 37% | Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 32% | Percent of long-stay residents whose need for help with daily activities has increased |
| 29% | Percent of long-stay residents who received an antipsychotic medication |
| 18% | Percent of long-stay residents who self-report moderate to severe pain. |
| 13% | Percent of short-stay residents who newly received an antipsychotic medication |
| 8% | 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 |
| 6% | Percent of long-stay residents who lose too much weight |
| 5% | Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 4% | Percent of long-stay residents who were physically restrained |
| 3% | Percent of long-stay high-risk residents with pressure ulcers |
| 1% | Percent of long-stay residents experiencing one or more falls with major injury |
| 0% | Percent of long-stay residents who have depressive symptoms |
Hazardous Area: construction that can resist fire for one hour or an approved fire extinguishing system.
| Level of Harm: | Minimal harm or potential for actual harm | Scope: | Many |
| Survey Date: | 5/13/11 | Corrected By: | NA |
|
Nutrition and Dietary: Store, cook, and serve food in a safe and clean way.
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 5/13/11 | Corrected By: | 6/24/11 |
|
Exits and Egress: rooms that can be unlocked from inside without a key.
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 5/13/11 | Corrected By: | 5/26/11 |
|
Quality Care : Provide necessary care and services to maintain the highest well being of each resident .
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 7/27/12 | Corrected By: | NA |
|
Quality Care : Provide care by qualified persons according to each resident's written plan of care.
| Level of Harm: | Potential for minimal harm | Scope: | Some |
| Survey Date: | 7/27/12 | Corrected By: | NA |
|
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: | Some |
| Survey Date: | 6/24/10 | Corrected By: | 8/2/10 |
|
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: | 5/13/11 | Corrected By: | 6/24/11 |
|
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: | Some |
| Survey Date: | 7/27/12 | 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: | Minimal harm or potential for actual harm | Scope: | Some |
| Survey Date: | 5/13/11 | Corrected By: | NA |
|
Illumination and Emergency Power: emergency lighting that can last at least 1 1/2 hours.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 5/13/11 | Corrected By: | 6/24/11 |
|
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: | 5/13/11 | Corrected By: | 6/24/11 |
|
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: | 7/27/12 | Corrected By: | NA |
|
Resident Assessment: Conduct initial and periodic assessments of each resident's functional capacity.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 7/27/12 | Corrected By: | NA |
|
Corridor Walls and Doors: corridor and hallway doors that block smoke.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 5/13/11 | Corrected By: | 6/1/11 |
|
Miscellaneous: other fire safety features required by fire safety codes.
| Level of Harm: | Potential for minimal harm | Scope: | Few |
| Survey Date: | 5/13/11 | Corrected By: | 6/20/11 |
|
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: | 5/13/11 | Corrected By: | 6/24/11 |
|
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: | 7/27/12 | Corrected By: | NA |
|
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: | 5/13/11 | Corrected By: | 6/24/11 |
|
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: | 6/24/10 | Corrected By: | 9/19/10 |
|
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: | Few |
| Survey Date: | 6/24/10 | Corrected By: | 8/3/10 |
|