CMS Inspection Results for ALPHA MANOR NURSING HOME

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.

• 02/23/2009 Fire Safety Survey for ALPHA MANOR NURSING HOME

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Pattern	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
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

 

• 02/20/2009 Health Survey for ALPHA MANOR NURSING HOME

Administration
Deficiency	Scope	Level of Harm
Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that a resident does not become withdrawn, angry or depressed if these problems did not exist before.	Pattern	Minimal harm or potential for actual harm
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual 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 meet a professional standard of quality.	Pattern	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.	Pattern	Minimal harm or potential for actual harm
Develop/implement required procedures for the administration of immunizations.	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
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
Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Pattern	Minimal harm or potential for actual harm

 

• 01/25/2008 Health Survey for ALPHA MANOR NURSING HOME

Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
Keep temperature levels comfortable and safe.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	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
Offer other nutritional food to each resident who will not eat the food served.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
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.	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.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual 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

 

• 01/23/2008 Fire Safety Survey for ALPHA MANOR NURSING HOME

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	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.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm

 

• 03/30/2007 Health Survey for ALPHA MANOR NURSING HOME

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
Mistreatment
Deficiency	Scope	Level of Harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Use a registered nurse at least 8 hours a day, 7 days a week.	Pattern	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
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Assess the resident when the resident enters the nursing home, in a timely manner.	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

 

• 03/29/2007 Fire Safety Survey for ALPHA MANOR NURSING HOME

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
back-up procedures in place for a faulty automatic sprinkler system.	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
properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
corridor and hallway doors that block smoke.	Isolated	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
record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
did not have a written emergency evacuation plan.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
an approved back-up procedure for a faulty fire alarm system.	Isolated	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
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
proper backup exit lighting.	Isolated	Minimal harm or potential for actual harm
Interior Finish
Deficiency	Scope	Level of Harm
fire-resistant room wall surfaces.	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
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm