DECATUR TOWNSHIP CARE AND REHABILITATION CENTER IN DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
05/24/2010	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
05/24/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
05/24/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
05/24/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
05/24/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
05/14/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
05/14/2010	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
05/14/2010	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
05/14/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
04/23/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
04/23/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
05/08/2008	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Minimal harm or potential for actual harm
05/08/2008	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
05/08/2008	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
05/08/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
05/08/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
05/08/2008	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
05/08/2008	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
05/08/2008	properly sized and located linen or trash receptacles.	Pattern	Minimal harm or potential for actual harm
05/08/2008	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
05/08/2008	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
05/08/2008	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
05/05/2008	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
05/05/2008	Let residents talk to and get information from agencies acting on their behalf.	Pattern	Minimal harm or potential for actual harm
05/05/2008	Protect residents from mistreatment, neglect, and/or theft of personal property.	Pattern	Minimal harm or potential for actual harm
05/05/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
05/05/2008	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
05/05/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
05/05/2008	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
05/05/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
05/05/2008	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
05/05/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
05/05/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
05/05/2008	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
05/05/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	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