DESERET NURSING & REHABILITATION AT WICHITA LLC KS DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/10/2009	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
12/10/2009	Send and promptly deliver unopened mail to residents.	Widespread	Potential for minimal harm
12/10/2009	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/10/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
12/10/2009	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
12/10/2009	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
12/10/2009	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
12/10/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
12/10/2009	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
12/10/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
12/10/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/10/2009	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
12/10/2009	Keep accurate and appropriate medical records.	Widespread	Potential for minimal harm
10/15/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
10/15/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
10/15/2009	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
10/15/2009	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
10/15/2009	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
10/15/2009	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
10/15/2009	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
10/15/2009	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
10/15/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
10/15/2009	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
10/15/2009	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
10/15/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
12/08/2008	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.	Widespread	Potential for minimal harm
12/08/2008	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
12/08/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
12/08/2008	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
12/08/2008	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
12/08/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/08/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
12/08/2008	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
12/08/2008	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
12/08/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/08/2008	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
12/08/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
12/08/2008	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
12/08/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
12/08/2008	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
12/08/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
12/08/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
12/08/2008	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.	Isolated	Minimal harm or potential for actual harm
12/08/2008	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
12/08/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/08/2008	Give or get dental care for each resident.	Isolated	Minimal harm or potential for actual harm
12/08/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
12/08/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
12/08/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
12/08/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/08/2008	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
12/08/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
12/08/2008	Keep accurate and appropriate medical records.	Widespread	Potential for minimal harm
12/08/2008	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
08/29/2008	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
08/29/2008	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
08/29/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
08/29/2008	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
08/29/2008	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
08/29/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
08/29/2008	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
08/29/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
08/29/2008	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
08/29/2008	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
08/29/2008	emergency showers.	Widespread	Minimal harm or potential for actual harm
10/26/2007	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
10/26/2007	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
10/26/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
10/26/2007	exits that are accessible at all times.	Widespread	Immediate jeopardy to resident health or safety
10/26/2007	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
10/26/2007	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
10/26/2007	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
10/26/2007	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
10/26/2007	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
10/26/2007	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
10/26/2007	properly constructed linen or trash chutes.	Pattern	Minimal harm or potential for actual harm
10/26/2007	restrictions on the use of flammable curtains.	Isolated	Minimal harm or potential for actual harm
10/26/2007	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
10/26/2007	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/23/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
10/23/2007	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
10/23/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/23/2007	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
10/23/2007	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
10/23/2007	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
10/23/2007	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
10/23/2007	post nurse staffing information.	Widespread	Potential for minimal harm
10/23/2007	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
10/23/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
10/23/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/23/2007	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
10/23/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
10/23/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
10/23/2007	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.	Isolated	Minimal harm or potential for actual harm
10/23/2007	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
10/23/2007	Bill properly: Charged resident for items that Medicare or Medicaid pays for.	Isolated	Minimal harm or potential for actual harm
10/23/2007	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
10/23/2007	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/23/2007	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
10/23/2007	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

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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