BORTZ HEALTH CARE OF TRAVERSE CITY MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
10/21/2010	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
10/21/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
10/21/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/21/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
10/21/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/21/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/21/2010	a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
10/21/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
10/21/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
10/21/2010	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
10/21/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
10/21/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
10/21/2010	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
10/21/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
10/21/2010	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
10/21/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
10/21/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
10/21/2010	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
12/03/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
12/03/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/03/2009	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
12/03/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
12/02/2009	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
12/02/2009	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
12/02/2009	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
12/02/2009	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.	Pattern	Minimal harm or potential for actual harm
12/02/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/02/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
12/02/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Potential for minimal harm
10/23/2008	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
10/23/2008	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.	Pattern	Minimal harm or potential for actual harm
10/23/2008	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
10/23/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
10/23/2008	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
10/23/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
10/23/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/23/2008	Keep temperature levels comfortable and safe.	Pattern	Minimal harm or potential for actual harm
10/23/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
10/23/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/23/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/23/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
10/23/2008	Keep all essential equipment working safely.	Widespread	Minimal harm or potential for actual harm
10/23/2008	Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) an adequate bed; 4) furniture that meets the resident's needs; or 5) enough closet space.	Isolated	Minimal harm or potential for actual harm
10/23/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
10/23/2008	fire-resistant interior walls.	Widespread	Minimal harm or potential for actual harm
10/23/2008	fire-resistant room wall surfaces.	Widespread	Minimal harm or potential for actual harm
10/23/2008	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
10/23/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
10/23/2008	restrictions on the use of flammable curtains.	Widespread	Minimal harm or potential for actual harm
10/23/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
10/23/2008	properly installed hallway dispensers for alcohol-based hand rub.	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