CHINLE NURSING HOME AZ DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
09/28/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
09/28/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
09/28/2010	rooms that can be unlocked from inside without a key.	Isolated	Minimal harm or potential for actual harm
09/28/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
09/28/2010	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
09/28/2010	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
09/28/2010	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
09/28/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
09/28/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm
09/28/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
09/17/2010	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
09/17/2010	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
09/17/2010	Keep temperature levels comfortable and safe.	Pattern	Potential for minimal harm
09/17/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
09/17/2010	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
09/17/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
09/17/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
09/17/2010	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
09/17/2010	1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator.	Widespread	Minimal harm or potential for actual harm
09/17/2010	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
09/17/2010	Get services outside the nursing home that meet professional standards.	Widespread	Minimal harm or potential for actual harm
09/17/2010	Choose a doctor to be the medical director.	Widespread	Minimal harm or potential for actual harm
09/17/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
09/17/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
09/17/2010	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
09/17/2010	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
09/24/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
09/24/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
09/24/2009	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
09/24/2009	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
09/24/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
09/24/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
09/24/2009	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
09/24/2009	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
09/24/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
09/17/2009	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
09/17/2009	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
09/17/2009	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Potential for minimal harm
09/17/2009	Provide written records when a resident is transferred or discharged.	Isolated	Minimal harm or potential for actual harm
09/17/2009	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
09/17/2009	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
09/17/2009	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
09/17/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
09/17/2009	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
09/17/2009	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.	Pattern	Potential for minimal harm
09/17/2009	Give professional services that follow each resident's written care plan.	Isolated	Actual harm
09/17/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
09/17/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Get rid of garbage properly.	Pattern	Potential for minimal harm
09/17/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Potential for minimal harm
09/17/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Potential for minimal harm
09/17/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/17/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Have enough backup water supply for important areas of the nursing home.	Widespread	Minimal harm or potential for actual harm
09/17/2009	Keep accurate and appropriate medical records.	Widespread	Potential for minimal harm
09/17/2009	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
08/28/2008	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
08/28/2008	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Minimal harm or potential for actual harm
08/28/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
08/28/2008	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
08/28/2008	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
08/28/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
08/28/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
08/28/2008	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
08/28/2008	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
08/28/2008	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
08/28/2008	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
08/28/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
08/28/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
08/28/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
08/28/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
08/28/2008	post nurse staffing information.	Pattern	Potential for minimal harm
08/28/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
08/28/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
08/28/2008	Properly mark drugs and other similar products.	Widespread	Potential for minimal harm
08/28/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
08/28/2008	Train all employees on what to do in an emergency.	Pattern	Potential for minimal harm
08/25/2008	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
08/25/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
08/25/2008	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
08/25/2008	properly sized and located linen or trash receptacles.	Widespread	Minimal harm or potential for actual harm
08/25/2008	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
08/25/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
08/25/2008	signs that state that exit doors are to be kept closed.	Pattern	Minimal harm or potential for actual harm
08/25/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
08/25/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
08/25/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
08/25/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
08/25/2008	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
08/25/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
08/25/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
08/25/2008	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
08/25/2008	an approved back-up procedure for a faulty fire alarm system.	Widespread	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