GLADE VALLEY CENTER MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/25/2011	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
11/15/2010	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
11/15/2010	proper medical gas storage and administration areas.	Pattern	Potential for minimal harm
11/15/2010	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
11/15/2010	no-smoking signs where oxygen is used.	Widespread	Potential for minimal harm
11/05/2009	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
11/05/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
11/05/2009	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
11/05/2009	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.	Pattern	Minimal harm or potential for actual harm
11/05/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
11/05/2009	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
11/05/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
11/05/2009	Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
10/21/2009	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
10/21/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Potential for minimal harm
10/21/2009	two separate exits in rooms of more than 1000 square feet.	Isolated	Minimal harm or potential for actual harm
10/21/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
10/21/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
10/31/2008	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
10/31/2008	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
10/31/2008	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
10/31/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/31/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
10/31/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
10/31/2008	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
10/31/2008	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
10/31/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
10/31/2008	Keep complete, dated lab records in the resident's file.	Isolated	Minimal harm or potential for actual harm
10/31/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
10/01/2008	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
10/01/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
10/01/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/01/2008	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