GLEN HAVEN HEALTH AND REHABILITATION, LLC AL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/02/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
12/02/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
12/02/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
12/02/2010	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
12/02/2010	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
12/02/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
12/02/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
12/02/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
12/02/2010	proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm
12/02/2010	a separate and independent backup electrical power source.	Widespread	Minimal harm or potential for actual harm
11/11/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
11/11/2010	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
11/11/2010	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
11/11/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
09/03/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
09/03/2009	did not have a written emergency evacuation plan.	Widespread	Potential for minimal harm
09/03/2009	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
09/03/2009	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
09/03/2009	proper medical gas storage and administration areas.	Widespread	Potential for minimal harm
09/03/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
09/02/2009	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
09/02/2009	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
09/02/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
09/02/2009	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
09/11/2008	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
09/11/2008	Send and promptly deliver unopened mail to residents.	Widespread	Potential for minimal harm
09/11/2008	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
09/11/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
09/11/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
09/11/2008	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
09/11/2008	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
09/11/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Widespread	Minimal harm or potential for actual harm
09/11/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
09/11/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/10/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
09/10/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
09/10/2008	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
09/10/2008	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
09/10/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	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