FUTURE CARE IRVINGTON, LLC MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/03/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
03/03/2010	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
03/03/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
03/03/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
03/03/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
03/03/2010	restrictions on the use of portable space heaters.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
12/10/2009	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
12/10/2009	Give professional services that meet a professional standard of quality.	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.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
12/10/2009	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
12/10/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Have enough outside airflow.	Widespread	Potential for minimal harm
12/10/2009	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Widespread	Potential for minimal harm
08/03/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
08/03/2009	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
08/03/2009	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
08/03/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
08/03/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
08/03/2009	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
08/03/2009	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
08/03/2009	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
08/03/2009	restrictions on the use of highly flammable materials.	Pattern	Minimal harm or potential for actual harm
12/30/2008	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
12/30/2008	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
12/30/2008	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
12/30/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/30/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Potential for minimal harm
12/30/2008	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
12/30/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
12/30/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
12/30/2008	Make sure that a doctor approves a resident's admission in writing and that each resident has a doctor.	Isolated	Minimal harm or potential for actual harm
12/30/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
01/11/2008	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.	Pattern	Minimal harm or potential for actual harm
01/11/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
01/11/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/11/2008	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
01/11/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/11/2008	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
01/11/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Actual harm
01/11/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
01/11/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
09/24/2007	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Potential for minimal harm
09/24/2007	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Potential for minimal harm
09/24/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
09/24/2007	proper backup exit lighting.	Pattern	Potential for minimal harm
09/24/2007	properly located and lighted "Exit" signs.	Pattern	Potential for minimal harm
09/24/2007	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Potential for minimal harm
09/24/2007	restrictions on the use of portable space heaters.	Pattern	Potential for minimal harm
09/24/2007	proper medical gas storage and administration areas.	Pattern	Potential for minimal harm
09/24/2007	fire safety features required by current fire safety codes.	Pattern	Potential for minimal harm
09/24/2007	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Potential for minimal 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