CATHOLIC CARE CENTER KS DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/18/2010	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.	Pattern	Minimal harm or potential for actual harm
03/18/2010	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
03/18/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
03/18/2010	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
03/18/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
03/18/2010	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
03/18/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
03/18/2010	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Widespread	Minimal harm or potential for actual harm
03/18/2010	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
12/01/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
12/23/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/23/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/23/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
12/23/2008	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
12/23/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
12/23/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/15/2008	a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
10/15/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
10/15/2008	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
10/15/2008	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
10/15/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
10/15/2008	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
10/15/2008	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
10/15/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
10/15/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
10/15/2008	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
10/15/2008	properly sized and located linen or trash receptacles.	Isolated	Minimal harm or potential for actual harm
10/15/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
10/31/2007	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.	Pattern	Potential for minimal harm
10/31/2007	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
10/31/2007	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal harm
10/31/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
10/31/2007	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
10/31/2007	Do a new assessment after any major change in a resident's physical or mental health.	Pattern	Minimal harm or potential for actual harm
10/31/2007	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
10/31/2007	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
10/31/2007	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
10/31/2007	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
10/31/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/31/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
10/11/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
10/11/2007	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
10/11/2007	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
10/11/2007	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
10/11/2007	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
10/11/2007	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
10/11/2007	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
10/11/2007	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
10/11/2007	properly installed electrical wiring and equipment.	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