CMS Inspection Results for MANDA ANN CONVALESCENT HOME INC

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.

• 06/27/2008 Health Survey for MANDA ANN CONVALESCENT HOME INC

Administration
Deficiency	Scope	Level of Harm
Give lab tests only when the attending doctor ordered them.	Isolated	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
Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection.	Pattern	Minimal harm or potential for actual harm
Keep all essential equipment working safely.	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
Use a registered nurse at least 8 hours a day, 7 days a week.	Widespread	Minimal harm or potential for actual harm

 

• 06/26/2008 Fire Safety Survey for MANDA ANN CONVALESCENT HOME INC

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
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
properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
an externally vented heating system.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	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.	Widespread	Minimal harm or potential for actual harm
properly maintained smoke detectors.	Isolated	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.	Widespread	Minimal harm or potential for actual harm
proper backup exit lighting.	Isolated	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

 

• 07/12/2007 Health Survey for MANDA ANN CONVALESCENT HOME INC

Environmental
Deficiency	Scope	Level of Harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Make sure that a working call system is available in each resident's room or bathroom and bathing area.	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
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Provide activities to meet the needs of each resident.	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.	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
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 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
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Potential for minimal harm

 

• 07/11/2007 Fire Safety Survey for MANDA ANN CONVALESCENT HOME INC

Building Service Equipment
Deficiency	Scope	Level of Harm
properly protected cooking facilities.	Widespread	Potential for minimal 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
a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Widespread	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.	Pattern	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm

 

• 08/14/2006 Fire Safety Survey for MANDA ANN CONVALESCENT HOME INC

Building Contruction
Deficiency	Scope	Level of Harm
approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
properly installed electrical wiring and equipment.	Widespread	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.	Isolated	Minimal harm or potential for actual harm
record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	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
proper construction of ducts through walls designed to prevent smoke passage.	Isolated	Minimal harm or potential for actual harm
Vertical Openings
Deficiency	Scope	Level of Harm
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Widespread	Minimal harm or potential for actual harm

 

• 08/10/2006 Health Survey for MANDA ANN CONVALESCENT HOME INC

Environmental
Deficiency	Scope	Level of Harm
Make sure there is a program to prevent/deal with mice, insects, or other pests.	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
Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of 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
Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of 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
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm