FATHER MURRAY NURSING CENTER MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/14/2011	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
01/14/2011	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
01/14/2011	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
01/14/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/14/2011	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
01/14/2011	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
01/14/2011	Properly mark drugs and other similar products.	Widespread	Minimal harm or potential for actual harm
01/13/2011	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
01/13/2011	exit stairways and towers that are smoke proof.	Widespread	Minimal harm or potential for actual harm
01/13/2011	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
01/13/2011	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
01/13/2011	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
01/13/2011	proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Minimal harm or potential for actual harm
01/13/2011	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
03/05/2010	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
03/05/2010	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Minimal harm or potential for actual harm
03/05/2010	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
03/05/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
03/05/2010	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
03/05/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
03/05/2010	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
03/05/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
03/05/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
03/05/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
03/05/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
03/05/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
03/05/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
03/05/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
03/05/2010	properly installed hallway dispensers for alcohol-based hand rub.	Widespread	Minimal harm or potential for actual harm
04/03/2009	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
04/03/2009	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
04/03/2009	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
04/03/2009	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
04/03/2009	Keep assessments completed in the preceding 15 months in the resident's active record.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
04/03/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
04/03/2009	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
04/03/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
04/03/2009	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
04/03/2009	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.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
04/03/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
04/03/2009	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
04/03/2009	exit stairways and towers that are smoke proof.	Widespread	Minimal harm or potential for actual harm
04/03/2009	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
04/03/2009	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
04/03/2009	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
04/03/2009	properly installed electrical wiring and equipment.	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