BRECKENRIDGE HEALTH & REHABILITATION IN DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/15/2011	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
02/15/2011	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
02/15/2011	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
02/15/2011	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
02/15/2011	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
02/15/2011	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
02/15/2011	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
02/15/2011	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
01/14/2011	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.	Widespread	Potential for minimal harm
01/14/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/14/2011	post nurse staffing information.	Widespread	Potential for minimal harm
01/14/2011	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
01/14/2011	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
01/14/2011	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/14/2011	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
02/25/2010	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
02/25/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
02/25/2010	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
02/25/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
02/25/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
02/25/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Immediate jeopardy to resident health or safety
02/25/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Actual harm
02/25/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
02/25/2010	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
02/25/2010	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
02/25/2010	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
02/18/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
02/18/2010	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
02/18/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
02/18/2010	a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
02/18/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
02/18/2010	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
02/18/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
05/15/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
04/30/2009	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	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.	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