BRASWELL'S IVY RETREAT CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/09/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
12/09/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
12/09/2010	properly sized and located linen or trash receptacles.	Isolated	Minimal harm or potential for actual harm
12/09/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
12/06/2010	Give the resident's legal representative the same rights as the resident.	Isolated	Minimal harm or potential for actual harm
12/06/2010	Provide written records when a resident is transferred or discharged.	Isolated	Minimal harm or potential for actual harm
12/06/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/06/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/06/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
12/06/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Potential for minimal harm
12/06/2010	Hire enough skilled workers to carry out dietary service.	Isolated	Minimal harm or potential for actual harm
12/06/2010	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
12/06/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/06/2010	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
12/06/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
12/06/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/06/2010	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
12/06/2010	Provide rooms that are big enough for each resident.	Pattern	Minimal harm or potential for actual harm
12/06/2010	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
12/06/2010	Be administered in a way that leads to the highest possible level of well being for each resident.	Isolated	Minimal harm or potential for actual harm
12/06/2010	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Pattern	Minimal harm or potential for actual harm
11/06/2009	Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility.	Isolated	Minimal harm or potential for actual harm
11/06/2009	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
11/06/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
11/06/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
11/06/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
11/06/2009	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
11/06/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
11/06/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
11/06/2009	Get proof that a nurse aide has the training and skills that the State requires.	Isolated	Minimal harm or potential for actual harm
11/03/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
11/03/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
11/03/2009	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
11/03/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
11/03/2009	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
11/03/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
12/11/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
12/11/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
12/11/2008	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
12/11/2008	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
12/11/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
12/11/2008	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
12/10/2008	Tell the resident completely about his or her health status.	Pattern	Minimal harm or potential for actual harm
12/10/2008	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
12/10/2008	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
12/10/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
12/10/2008	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
12/10/2008	Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
12/10/2008	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	Minimal harm or potential for actual harm
12/10/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/10/2008	Make sure that each resident gets help to keep vision and hearing.	Pattern	Minimal harm or potential for actual harm
12/10/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/10/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
12/10/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
12/10/2008	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
12/10/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/10/2008	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
12/10/2008	Give or get dental care for each resident.	Isolated	Minimal harm or potential for actual harm
12/10/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Widespread	Minimal harm or potential for actual harm
12/10/2008	Properly mark drugs and other similar products.	Widespread	Minimal harm or potential for actual harm
12/10/2008	Have a program to keep infection from spreading.	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