COUNTRY COTTAGE CARE AND REHABILITATION NM DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
08/13/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
08/13/2010	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
08/13/2010	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
08/13/2010	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
08/13/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
08/13/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
08/13/2010	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
08/13/2010	Give or get dental care for each resident.	Isolated	Minimal harm or potential for actual harm
08/13/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
08/10/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
08/10/2010	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
08/10/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
08/10/2010	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
08/10/2010	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
08/10/2010	fire safety features required by current fire safety codes.	Widespread	Minimal harm or potential for actual harm
08/10/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
09/16/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
09/16/2009	the appropriate emergency electrical equipment.	Widespread	Minimal harm or potential for actual harm
09/04/2008	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	Minimal harm or potential for actual harm
09/04/2008	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
09/04/2008	Have a private telephone available for use.	Widespread	Potential for minimal harm
09/04/2008	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal harm
09/04/2008	Give enough notice to the resident before changing the resident's room or roommate.	Isolated	Minimal harm or potential for actual harm
09/04/2008	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
09/04/2008	Hire a qualified activities director.	Widespread	Potential for minimal harm
09/04/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Actual harm
09/04/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Actual harm
09/04/2008	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Minimal harm or potential for actual harm
09/04/2008	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
09/04/2008	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
09/04/2008	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal harm
09/04/2008	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
09/04/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Actual harm
09/04/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
09/04/2008	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Actual harm
09/04/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
09/04/2008	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.	Pattern	Minimal harm or potential for actual harm
09/04/2008	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Minimal harm or potential for actual harm
09/04/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
09/04/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/04/2008	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Widespread	Potential for minimal harm
09/04/2008	Follow all laws and professional standards.	Pattern	Minimal harm or potential for actual harm
09/04/2008	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
08/27/2008	signs that state that exit doors are to be kept closed.	Widespread	Minimal harm or potential for actual harm
08/27/2008	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
08/27/2008	properly installed electrical wiring and equipment.	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