BLUE RIVER REHABILITATION CENTER MO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
04/14/2010	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
04/14/2010	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
04/14/2010	Keep safe, clean and homelike surroundings.	Pattern	Potential for minimal harm
04/14/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
04/14/2010	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
04/14/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Potential for minimal harm
04/14/2010	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
04/14/2010	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.	Pattern	Potential for minimal harm
04/14/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
04/14/2010	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal harm
04/14/2010	Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress.	Pattern	Potential for minimal harm
04/14/2010	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
04/14/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
04/14/2010	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
04/14/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
04/14/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
04/14/2010	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Potential for minimal harm
04/14/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Potential for minimal harm
04/14/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
04/14/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
04/14/2010	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
04/14/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
04/14/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
04/14/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
04/14/2010	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
04/14/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
04/14/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
04/14/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
04/14/2010	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
04/14/2010	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
04/14/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm
04/14/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
04/14/2010	emergency showers.	Pattern	Minimal harm or potential for actual harm
04/30/2009	Send and promptly deliver unopened mail to residents.	Pattern	Potential for minimal harm
04/30/2009	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
04/30/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
04/30/2009	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
04/30/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/30/2009	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
04/30/2009	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
04/30/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
04/30/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
04/30/2009	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
04/30/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
04/30/2009	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
04/30/2009	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
04/30/2009	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
04/30/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
06/25/2008	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
06/25/2008	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Minimal harm or potential for actual harm
06/25/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
06/25/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
06/25/2008	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
06/25/2008	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
06/25/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
06/25/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
06/25/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
06/25/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
06/25/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Actual harm
06/25/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
06/25/2008	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
06/25/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
06/25/2008	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
06/25/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
06/25/2008	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Isolated	Minimal harm or potential for actual harm
06/25/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
06/25/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
06/25/2008	Have enough outside airflow.	Pattern	Minimal harm or potential for actual harm
06/25/2008	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
06/25/2008	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
06/25/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
06/25/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
06/25/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
06/25/2008	weekly inspections and monthly testing of generators.	Pattern	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