DESERET NURSING & REHABILITATION AT MCPHERSON KS DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/16/2008	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
12/16/2008	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
12/16/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/17/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
10/17/2008	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
10/17/2008	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
10/17/2008	properly located and lighted "Exit" signs.	Widespread	Minimal harm or potential for actual harm
10/17/2008	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
10/17/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
10/17/2008	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
10/17/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
10/17/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/17/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
10/17/2008	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
10/17/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
12/21/2007	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
12/21/2007	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.	Isolated	Minimal harm or potential for actual harm
12/21/2007	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
12/21/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
12/21/2007	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
12/21/2007	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
12/21/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/21/2007	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
11/14/2007	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm
11/14/2007	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
11/14/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
11/14/2007	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
11/14/2007	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
11/14/2007	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
11/14/2007	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
11/14/2007	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
11/14/2007	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
11/14/2007	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
11/20/2006	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
11/20/2006	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
11/20/2006	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
11/20/2006	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
11/20/2006	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
11/20/2006	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/20/2006	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
11/20/2006	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Widespread	Minimal harm or potential for actual harm
11/20/2006	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
11/20/2006	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
08/01/2006	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
08/01/2006	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
08/01/2006	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
08/01/2006	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
08/01/2006	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
08/01/2006	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
08/01/2006	restrictions on the use of flammable curtains.	Widespread	Minimal harm or potential for actual harm
08/01/2006	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
08/01/2006	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
08/01/2006	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
08/01/2006	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
08/01/2006	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
08/01/2006	approved construction type or materials.	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