BROADMEADOW HEALTHCARE DE DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/18/2011	Give enough notice to the resident before changing the resident's room or roommate.	Pattern	Potential for minimal harm
01/18/2011	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
01/18/2011	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
01/18/2011	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
01/18/2011	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
01/18/2011	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
01/11/2011	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
01/11/2011	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
01/11/2011	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
02/25/2009	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
02/25/2009	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
02/25/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Potential for minimal harm
02/25/2009	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.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Provide clean bed and bath linens that are in good condition.	Pattern	Potential for minimal harm
02/25/2009	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
02/25/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
02/25/2009	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
02/25/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/25/2009	Get rid of garbage properly.	Pattern	Potential for minimal harm
02/25/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
02/25/2009	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
02/25/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
02/25/2009	Have enough outside airflow.	Pattern	Minimal harm or potential for actual harm
02/25/2009	Get services outside the nursing home that meet professional standards.	Pattern	Potential for minimal harm
02/25/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
02/18/2009	properly protected cooking facilities.	Widespread	Potential for minimal harm
02/18/2009	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
02/18/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
02/18/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Potential for minimal harm
02/18/2009	exits that are accessible at all times.	Widespread	Potential for minimal harm
02/18/2009	weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
02/18/2009	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
02/18/2009	portable fire extinguishers.	Widespread	Potential for minimal harm
02/01/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
02/01/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
02/01/2008	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
02/01/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
02/01/2008	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
02/01/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
02/01/2008	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
02/01/2008	Hire enough skilled workers to carry out dietary service.	Pattern	Minimal harm or potential for actual harm
02/01/2008	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
02/01/2008	Offer other nutritional food to each resident who will not eat the food served.	Pattern	Minimal harm or potential for actual harm
02/01/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/01/2008	Have a program to keep infection from spreading.	Widespread	Potential for minimal harm
02/01/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
02/01/2008	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
02/01/2008	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
02/01/2008	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
02/01/2008	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
02/01/2008	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
02/01/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
01/31/2008	properly protected cooking facilities.	Widespread	Potential for minimal harm
01/31/2008	restrictions on the use of highly flammable materials.	Widespread	Potential for minimal harm
01/31/2008	proper medical gas storage and administration areas.	Widespread	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