ARBOR SPRINGS HEALTH AND REHAB CENTER, LTD AL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/11/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
03/11/2010	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
03/11/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Potential for minimal harm
03/11/2010	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
03/11/2010	did not have a written emergency evacuation plan.	Isolated	Minimal harm or potential for actual harm
03/11/2010	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
03/11/2010	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
03/11/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
03/11/2010	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
03/11/2010	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
03/04/2010	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
03/04/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
03/04/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
02/10/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/10/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
02/10/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
02/10/2009	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
02/10/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
02/10/2009	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
02/05/2009	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Minimal harm or potential for actual harm
02/05/2009	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
02/05/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
02/05/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
02/05/2009	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
01/24/2008	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
01/24/2008	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
01/24/2008	a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
01/24/2008	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
01/24/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/10/2008	Try to resolve each resident's complaints quickly.	Widespread	Minimal harm or potential for actual harm
01/10/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
01/10/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
01/10/2008	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
01/10/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
01/10/2008	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
01/10/2008	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
01/10/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
01/10/2008	Get rid of garbage properly.	Widespread	Potential for minimal harm
01/10/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
01/10/2008	Keep all essential equipment working safely.	Widespread	Potential for minimal harm
01/10/2008	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Widespread	Minimal harm or potential for actual harm
01/10/2008	Have licensed, certified, or registered staff to give needed services.	Widespread	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