CMS Inspection Results for ANTLERS MANOR, LLC

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.

• 03/14/2008 Health Survey for ANTLERS MANOR, LLC

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
Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
Make sure that nurse aides show they have the skills to be able to care for residents.	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.	Isolated	Immediate jeopardy to resident health or safety
Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
Make sure that staff members wash their hands when needed.	Pattern	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
Put firmly secured handrails on each side of hallways.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	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.	Widespread	Minimal harm or potential for actual harm
Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual 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.	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
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
Quality Care
Deficiency	Scope	Level of Harm
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
Use a registered nurse at least 8 hours a day, 7 days a week.	Widespread	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
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
Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	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.	Pattern	Minimal harm or potential for actual harm
Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	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
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
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	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.	Pattern	Potential for minimal 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.	Pattern	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
Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
Have a private telephone available for use.	Pattern	Potential for minimal harm

 

• 03/11/2008 Fire Safety Survey for ANTLERS MANOR, LLC

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm

 

• 05/18/2007 Health Survey for ANTLERS MANOR, LLC

Environmental
Deficiency	Scope	Level of Harm
Keep sound levels comfortable.	Pattern	Minimal harm or potential for actual harm
Get rid of garbage properly.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	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 residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
Provide activities to meet the needs of each resident.	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.	Isolated	Minimal harm or potential for actual harm

 

• 05/16/2007 Fire Safety Survey for ANTLERS MANOR, LLC

Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal 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.	Pattern	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.	Widespread	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
properly maintained smoke detectors.	Widespread	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.	Widespread	Minimal harm or potential for actual harm
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm

 

• 07/13/2006 Fire Safety Survey for ANTLERS MANOR, LLC

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
Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm

 

• 07/12/2006 Health Survey for ANTLERS MANOR, LLC

Environmental
Deficiency	Scope	Level of Harm
Provide needed housekeeping and maintenance.	Pattern	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.	Widespread	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Minimal harm or potential for actual harm