BEL PRE HEALTH & REHABILITATION CENTER MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/17/2010	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
03/17/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Potential for minimal harm
03/17/2010	exit stairways and towers that are smoke proof.	Isolated	Minimal harm or potential for actual harm
03/17/2010	properly located and lighted "Exit" signs.	Pattern	Potential for minimal harm
03/17/2010	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Potential for minimal harm
03/17/2010	proper medical gas storage and administration areas.	Widespread	Potential for minimal harm
03/17/2010	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
03/15/2010	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
03/15/2010	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
03/15/2010	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
03/15/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
03/15/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
03/15/2010	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
03/15/2010	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
03/15/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
03/15/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
03/15/2010	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
03/15/2010	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
03/15/2010	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
03/15/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
02/10/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
02/10/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
02/10/2009	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
02/10/2009	Give or get dental care for each resident.	Isolated	Minimal harm or potential for actual harm
02/10/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Potential for minimal harm
02/10/2009	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
02/10/2009	Get services outside the nursing home that meet professional standards.	Pattern	Minimal harm or potential for actual harm
02/10/2009	Give lab tests only when the attending doctor ordered them.	Pattern	Potential for minimal harm
10/09/2008	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
10/09/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Potential for minimal harm
10/09/2008	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Potential for minimal harm
10/09/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
10/09/2008	properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
12/07/2007	Let each resident choose a personal doctor.	Widespread	Potential for minimal harm
12/07/2007	Try to resolve each resident's complaints quickly.	Pattern	Potential for minimal harm
12/07/2007	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
12/07/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/07/2007	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
12/07/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
12/07/2007	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
12/07/2007	post nurse staffing information.	Pattern	Potential for minimal harm
12/07/2007	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Minimal harm or potential for actual harm
12/07/2007	Put a bathroom in or next to each resident's room.	Pattern	Minimal harm or potential for actual harm
12/07/2007	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Minimal harm or potential for actual harm
09/12/2007	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
09/12/2007	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Potential for minimal harm
09/12/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
09/12/2007	properly located and lighted "Exit" signs.	Pattern	Potential for minimal harm
09/12/2007	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Potential for minimal harm
09/12/2007	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
09/12/2007	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Potential for minimal harm
09/12/2007	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Potential for minimal harm
09/12/2007	properly protected cooking facilities.	Pattern	Potential for minimal harm
09/12/2007	properly installed electrical wiring and equipment.	Pattern	Potential for minimal 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