COLLEGE HILL NURSING & REHAB CENTER KS DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/05/2010	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
01/05/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal harm
01/05/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
01/05/2010	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
01/05/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/05/2010	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
01/05/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
01/05/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
01/05/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
01/05/2010	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
01/05/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
10/06/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
10/06/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
10/06/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
10/06/2009	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
10/06/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
11/13/2008	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.	Widespread	Potential for minimal harm
11/13/2008	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
11/13/2008	Give enough notice to the resident before changing the resident's room or roommate.	Isolated	Minimal harm or potential for actual harm
11/13/2008	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
11/13/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
11/13/2008	Keep sound levels comfortable.	Pattern	Minimal harm or potential for actual harm
11/13/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
11/13/2008	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
11/13/2008	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.	Isolated	Minimal harm or potential for actual harm
11/13/2008	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
11/13/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
11/13/2008	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
11/13/2008	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
11/13/2008	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
11/13/2008	Hire enough skilled workers to carry out dietary service.	Widespread	Minimal harm or potential for actual harm
11/13/2008	Properly mark drugs and other similar products.	Widespread	Minimal harm or potential for actual harm
11/13/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
11/13/2008	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
09/09/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
09/09/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
09/09/2008	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
09/09/2008	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
09/09/2008	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
09/09/2008	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
09/09/2008	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
09/09/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
09/09/2008	proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Minimal harm or potential for actual harm
09/09/2008	fire safety features required by current fire safety codes.	Widespread	Minimal harm or potential for actual harm
09/09/2008	emergency showers.	Isolated	Minimal harm or potential for actual harm
09/09/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
09/07/2007	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
09/07/2007	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
09/07/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
09/07/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
09/07/2007	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
09/07/2007	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
09/07/2007	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
09/07/2007	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.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
09/07/2007	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
09/07/2007	Hire a qualified dietician.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
09/07/2007	Get rid of garbage properly.	Pattern	Minimal harm or potential for actual harm
09/07/2007	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
09/07/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Get proof that a nurse aide has the training and skills that the State requires.	Pattern	Minimal harm or potential for actual harm
09/07/2007	Give lab tests only when the attending doctor ordered them.	Pattern	Minimal harm or potential for actual harm
08/28/2007	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
08/28/2007	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
08/28/2007	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
08/28/2007	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
08/28/2007	emergency showers.	Pattern	Minimal harm or potential for actual harm
08/28/2007	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