ABBEY WOODS MO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/29/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
03/29/2010	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
03/29/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
03/29/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
03/29/2010	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
03/29/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
03/29/2010	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
03/29/2010	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
03/29/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
03/29/2010	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
03/29/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
03/29/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
03/29/2010	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
03/29/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
03/29/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
03/29/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
03/29/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
03/29/2010	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
03/29/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
03/29/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
03/29/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
06/10/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
06/10/2009	Provide clean bed and bath linens that are in good condition.	Isolated	Minimal harm or potential for actual harm
06/10/2009	Keep sound levels comfortable.	Isolated	Minimal harm or potential for actual harm
06/10/2009	Give professional services that meet a professional standard of quality.	Widespread	Minimal harm or potential for actual harm
06/10/2009	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal harm
06/10/2009	post nurse staffing information.	Widespread	Potential for minimal harm
06/10/2009	Follow all laws and professional standards.	Widespread	Minimal harm or potential for actual harm
06/10/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
06/10/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
06/10/2009	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
06/10/2009	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
04/01/2008	Give the resident's legal representative the same rights as the resident.	Isolated	Minimal harm or potential for actual harm
04/01/2008	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Minimal harm or potential for actual harm
04/01/2008	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
04/01/2008	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.	Pattern	Minimal harm or potential for actual harm
04/01/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
04/01/2008	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
04/01/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
04/01/2008	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
04/01/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
04/01/2008	Give or get dental care for each resident.	Isolated	Minimal harm or potential for actual harm
04/01/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
04/01/2008	Train all employees on what to do in an emergency.	Widespread	Minimal harm or potential for actual harm
04/01/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
04/01/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
04/01/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
04/01/2008	properly protected cooking facilities.	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