BROOMFIELD SKILLED NURSING AND REHABILITATION CTR CO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/21/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
01/21/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
01/21/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
01/21/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
01/21/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
01/21/2010	restrictions on the use of flammable curtains.	Isolated	Minimal harm or potential for actual harm
01/21/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/21/2010	an elevator that firefighters can control in the event of a fire.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
12/23/2009	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.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/23/2009	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
12/23/2009	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
12/23/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
12/23/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
03/26/2009	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
03/26/2009	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
03/26/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
03/26/2009	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
03/26/2009	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
03/26/2009	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
03/26/2009	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
03/26/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
03/26/2009	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
03/26/2009	properly constructed linen or trash chutes.	Isolated	Minimal harm or potential for actual harm
03/26/2009	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
03/26/2009	proper fire barriers, ventilation and signs for the transport of oxygen.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
02/26/2009	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.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
02/26/2009	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/26/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
02/13/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/13/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
02/13/2008	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
02/13/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Provide care for each resident in a way that keeps or builds the resident's quality of life.	Pattern	Minimal harm or potential for actual harm
01/17/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm
01/17/2008	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
01/17/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/17/2008	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

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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