ELMS HAVEN CARE AND REHABILITATION CENTER CO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
04/16/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
04/16/2010	exit stairways and towers that are smoke proof.	Isolated	Minimal harm or potential for actual harm
04/16/2010	resident room doors of proper design and width.	Isolated	Minimal harm or potential for actual harm
04/16/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
04/16/2010	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
04/16/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
04/16/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
04/16/2010	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
04/16/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
04/16/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
03/22/2010	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
03/22/2010	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
03/22/2010	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
03/22/2010	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
03/22/2010	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
03/22/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
03/22/2010	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.	Pattern	Minimal harm or potential for actual harm
03/22/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
03/22/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
03/22/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
03/22/2010	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
03/22/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
03/22/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
03/22/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
03/22/2010	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
03/22/2010	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
03/22/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Immediate jeopardy to resident health or safety
03/22/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
03/22/2010	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
03/22/2010	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
03/22/2010	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
03/22/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
03/22/2010	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
03/22/2010	Make sure that doctors visit residents regularly, as required.	Pattern	Minimal harm or potential for actual harm
03/22/2010	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
03/22/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
03/22/2010	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
03/22/2010	Have enough outside airflow.	Pattern	Minimal harm or potential for actual harm
03/22/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
03/22/2010	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
01/15/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/15/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
01/15/2009	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
01/15/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
01/15/2009	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
01/15/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
12/17/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
12/17/2008	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Pattern	Minimal harm or potential for actual harm
12/17/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
12/17/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/17/2008	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
12/17/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/17/2008	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	Isolated	Minimal harm or potential for actual harm
12/17/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
12/17/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
12/17/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/17/2008	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
12/17/2008	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
12/17/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
12/17/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
12/17/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/17/2008	Give or get special rehabilitation if in the patient's plan of care.	Isolated	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	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
10/26/2007	smoke barrier doors that can resist smoke for at least 20 minutes.	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	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
10/26/2007	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
10/26/2007	automatic sprinkler systems that have been maintained in working order.	Widespread	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.	Pattern	Minimal harm or potential for actual harm
10/26/2007	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
10/26/2007	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
10/26/2007	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/03/2007	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/03/2007	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Actual harm
10/03/2007	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Pattern	Minimal harm or potential for actual harm
10/03/2007	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
10/03/2007	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
10/03/2007	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm
10/03/2007	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
10/03/2007	Develop a plan with the resident and family for the resident's care after leaving the nursing home.	Isolated	Minimal harm or potential for actual harm
10/03/2007	Screen residents when they are first admitted to send them to an area with special care for people with developmental disabilities or mental illness, if needed.	Isolated	Minimal harm or potential for actual harm
10/03/2007	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
10/03/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/03/2007	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.	Isolated	Minimal harm or potential for actual harm
10/03/2007	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
10/03/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
10/03/2007	Offer other nutritional food to each resident who will not eat the food served.	Pattern	Minimal harm or potential for actual harm
10/03/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/03/2007	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
10/03/2007	Keep accurate and appropriate medical records.	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