ASBURY TOWERS RETIREMENT COMMUNITY IN DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/03/2010	properly constructed windows in hallway walls or doors.	Pattern	Minimal harm or potential for actual harm
11/03/2010	signs that state that exit doors are to be kept closed.	Pattern	Minimal harm or potential for actual harm
11/03/2010	a two-hour-resistant firewall in common walls.	Pattern	Minimal harm or potential for actual harm
11/03/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
11/03/2010	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
11/03/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
11/03/2010	exit stairways and towers that are smoke proof.	Pattern	Minimal harm or potential for actual harm
11/03/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
11/03/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Immediate jeopardy to resident health or safety
11/03/2010	have an adequate water supply for the sprinkler system.	Pattern	Immediate jeopardy to resident health or safety
11/03/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
11/03/2010	restrictions on the use of portable space heaters.	Pattern	Minimal harm or potential for actual harm
11/03/2010	restrictions on the use of highly flammable materials.	Pattern	Minimal harm or potential for actual harm
11/03/2010	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
11/03/2010	fire-resistant Interior walls.	Pattern	Minimal harm or potential for actual harm
11/03/2010	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
11/03/2010	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Minimal harm or potential for actual harm
11/03/2010	back-up procedures in place for a faulty automatic sprinkler system.	Pattern	Immediate jeopardy to resident health or safety
10/22/2010	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
10/22/2010	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
10/22/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
10/22/2010	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Minimal harm or potential for actual harm
10/22/2010	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
10/22/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/22/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
09/25/2009	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
09/25/2009	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
09/25/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
09/25/2009	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
09/25/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
09/25/2009	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
09/25/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/25/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
09/25/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
09/25/2009	properly installed hallway dispensers for alcohol-based hand rub.	Pattern	Minimal harm or potential for actual harm
11/07/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
11/07/2008	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Minimal harm or potential for actual harm
11/07/2008	signs that state that exit doors are to be kept closed.	Pattern	Minimal harm or potential for actual harm
11/07/2008	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
11/07/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
11/07/2008	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
11/07/2008	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
11/07/2008	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
11/07/2008	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
11/07/2008	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
11/07/2008	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
11/07/2008	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
11/03/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
11/03/2008	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
11/03/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
11/03/2008	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
11/03/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
11/03/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
11/03/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
11/03/2008	Make sure that nurse aides show they have the skills to be able to care for residents.	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