CMS Inspection Results for DOUGLAS CARE CENTER

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.

• 04/24/2008 Health Survey for DOUGLAS CARE CENTER

Administration
Deficiency	Scope	Level of Harm
Set up or keep a group of people to review and ensure quality.	Pattern	Actual harm
post nurse staffing information.	Pattern	Potential for minimal harm
Environmental
Deficiency	Scope	Level of Harm
Stop employees, who have a disease that can spread, from having direct contact with residents or food.	Pattern	Actual harm
Make sure that staff members wash their hands when needed.	Widespread	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Make sure there is a program to prevent/deal with mice, insects, or other pests.	Isolated	Minimal harm or potential for actual harm
Keep adequate and comfortable lighting in all areas.	Pattern	Potential for minimal 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.	Isolated	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual 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 residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	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
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Develop/implement required procedures for the administration of immunizations.	Widespread	Potential for minimal harm
Resident Assessment
Deficiency	Scope	Level of Harm
Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal 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

 

• 04/23/2008 Fire Safety Survey for DOUGLAS CARE CENTER

Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	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
Furnishings and Decorations
Deficiency	Scope	Level of Harm
restrictions on the use of flammable curtains.	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
Illumination and Emergency Power
Deficiency	Scope	Level of Harm
proper backup exit lighting.	Pattern	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

 

• 07/19/2007 Health Survey for DOUGLAS CARE CENTER

Administration
Deficiency	Scope	Level of Harm
Set up or keep a group of people to review and ensure quality.	Pattern	Actual harm
Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
Follow all laws and professional standards.	Pattern	Minimal harm or potential for actual harm
Keep complete, dated lab records in the resident's file.	Isolated	Minimal harm or potential for actual harm
Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
post nurse staffing information.	Pattern	Potential for minimal harm
Environmental
Deficiency	Scope	Level of Harm
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
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
Provide clean bed and bath linens that are in good condition.	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
Pharmacy Service
Deficiency	Scope	Level of Harm
At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Widespread	Minimal harm or potential for actual 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
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	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
Have enough nurses to care for every resident in a way that maximizes the resident's well being.	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
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 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
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Widespread	Minimal harm or potential for actual harm
Do a new assessment after any major change in a resident's physical or mental health.	Pattern	Minimal harm or potential for actual harm
Check and update (if needed) each resident's assessment every 3 months.	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	Minimal harm or potential for actual harm
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
Assess the resident when the resident enters the nursing home, in a timely manner.	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
Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
Have a private telephone available for use.	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
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
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

 

• 06/13/2007 Fire Safety Survey for DOUGLAS CARE CENTER

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	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.	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.	Widespread	Minimal harm or potential for actual harm
did not have a written emergency evacuation plan.	Widespread	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.	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.	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.	Pattern	Minimal harm or potential for actual harm
proper backup exit lighting.	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.	Pattern	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
smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	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

 

• 04/06/2006 Health Survey for DOUGLAS CARE CENTER

Administration
Deficiency	Scope	Level of Harm
Keep signed and dated reports of x-rays and other tests.	Isolated	Minimal harm or potential for actual harm
Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Provide needed housekeeping and maintenance.	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
Have a program to keep infection from spreading.	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 the nursing home area is safe, easy to use, clean and comfortable.	Isolated	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.	Isolated	Minimal harm or potential for actual harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Potential for minimal harm
Quality Care
Deficiency	Scope	Level of 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 residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of 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	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
Keep assessments completed in the preceding 15 months in the resident's active record.	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.	Pattern	Minimal harm or potential for actual harm

 

• 04/03/2006 Fire Safety Survey for DOUGLAS CARE CENTER

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
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
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of 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.	Isolated	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.	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.	Widespread	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
Vertical Openings
Deficiency	Scope	Level of Harm
proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm