ABBEY DELRAY SOUTH FL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/04/2010	Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility.	Isolated	Minimal harm or potential for actual harm
06/04/2010	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
06/04/2010	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
06/04/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
06/04/2010	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
06/04/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
06/04/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
06/04/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
06/04/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
06/02/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
05/20/2009	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
05/20/2009	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.	Widespread	Potential for minimal harm
05/20/2009	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
05/20/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
05/20/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
05/20/2009	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
05/20/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
05/20/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
05/20/2009	Get rid of garbage properly.	Widespread	Minimal harm or potential for actual harm
05/20/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
05/20/2009	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
05/20/2009	Put firmly secured handrails on each side of hallways.	Isolated	Minimal harm or potential for actual harm
05/20/2009	proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Minimal harm or potential for actual harm
05/21/2008	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	Potential for minimal harm
05/21/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
05/21/2008	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
05/21/2008	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
05/21/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
05/21/2008	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
05/21/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
05/21/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
05/21/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
05/21/2008	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

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death