COLLINGTON EPISCOPAL LIFE CARE MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/24/2010	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
06/24/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
06/08/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
06/08/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
06/08/2010	proper medical gas storage and administration areas.	Pattern	Potential for minimal harm
08/10/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
08/10/2009	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
08/10/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
08/10/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/23/2009	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
07/23/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Minimal harm or potential for actual harm
07/23/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
07/23/2009	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Provide enough emergency electricity.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Potential for minimal harm
07/23/2009	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
11/06/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
11/06/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
11/06/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
11/06/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
11/06/2008	hallway or ground-level exits in all residents' rooms.	Widespread	Minimal harm or potential for actual harm
11/06/2008	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
11/06/2008	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
11/06/2008	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
11/06/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/08/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
10/08/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
10/08/2008	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
10/08/2008	Give or get lab tests to meet the needs of residents.	Isolated	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