CMS Inspection Results for HARBORSIDE HEALTHCARE-LOUISVILLE REHAB & NURSING

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 02/26/2009 Health Survey for HARBORSIDE HEALTHCARE-LOUISVILLE REHAB & NURSING

Administration
Deficiency	Scope	Level of Harm
Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
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.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
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.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Isolated	Minimal harm or potential for actual harm
Have a private telephone available for use.	Isolated	Minimal harm or potential for actual harm
Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm

 

• 02/26/2009 Fire Safety Survey for HARBORSIDE HEALTHCARE-LOUISVILLE REHAB & NURSING

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
did not have a written emergency evacuation plan.	Pattern	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
restrictions on the use of highly flammable materials.	Pattern	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm

 

• 03/20/2008 Health Survey for HARBORSIDE HEALTHCARE-LOUISVILLE REHAB & NURSING

Administration
Deficiency	Scope	Level of Harm
Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Put firmly secured handrails on each side of hallways.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
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.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
Make sure that residents are well nourished.	Pattern	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Develop/implement required procedures for the administration of immunizations.	Widespread	Minimal harm or potential for actual harm
Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
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.	Isolated	Minimal harm or potential for actual harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm

 

• 03/18/2008 Fire Safety Survey for HARBORSIDE HEALTHCARE-LOUISVILLE REHAB & NURSING

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
Laboratories
Deficiency	Scope	Level of Harm
proper facilities for the use and storage of combustible liquids.	Pattern	Minimal harm or potential for actual harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm

 

• 02/15/2007 Health Survey for HARBORSIDE HEALTHCARE-LOUISVILLE REHAB & NURSING

Quality Care
Deficiency	Scope	Level of Harm
Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm

 

• 02/14/2007 Fire Safety Survey for HARBORSIDE HEALTHCARE-LOUISVILLE REHAB & NURSING

Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
Vertical Openings
Deficiency	Scope	Level of Harm
proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm