DEACONESS SPECIALTY CARE CENTER MO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/09/2010	Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
06/09/2010	Get services outside the nursing home that meet professional standards.	Pattern	Potential for minimal harm
06/09/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
06/09/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
06/09/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
06/09/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
06/09/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
06/09/2010	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
06/09/2010	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
06/09/2010	emergency showers.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Isolated	Minimal harm or potential for actual harm
04/10/2009	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
04/10/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Hire a qualified activities director.	Widespread	Potential for minimal harm
04/10/2009	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
04/10/2009	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.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
04/10/2009	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
04/10/2009	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
04/10/2009	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Have enough outside airflow.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Put firmly secured handrails on each side of hallways.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Train all employees on what to do in an emergency.	Widespread	Potential for minimal harm
04/10/2009	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
04/10/2009	fire-resistant room wall surfaces.	Widespread	Minimal harm or potential for actual harm
04/10/2009	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
04/10/2009	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
04/10/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
04/10/2009	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
04/10/2009	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
04/10/2009	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
04/10/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
04/10/2009	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
03/10/2008	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
03/10/2008	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
03/10/2008	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
03/10/2008	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
03/10/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
03/10/2008	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
03/10/2008	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
03/10/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
03/10/2008	Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home.	Isolated	Minimal harm or potential for actual harm
03/10/2008	Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress.	Pattern	Minimal harm or potential for actual harm
03/10/2008	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Actual harm
03/10/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
03/10/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
03/10/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
03/10/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
03/10/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
03/10/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
03/10/2008	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
03/10/2008	Put firmly secured handrails on each side of hallways.	Isolated	Minimal harm or potential for actual harm
03/10/2008	Follow all laws and professional standards.	Pattern	Minimal harm or potential for actual harm
03/10/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
03/10/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
03/10/2008	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
03/10/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
03/10/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
03/10/2008	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
03/10/2008	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
03/10/2008	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
03/10/2008	fire safety features required by current fire safety codes.	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