GOLDEN LIVINGCENTER - KAW RIVER KS DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/25/2010	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
03/25/2010	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.	Isolated	Minimal harm or potential for actual harm
03/25/2010	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.	Isolated	Minimal harm or potential for actual harm
03/25/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
03/25/2010	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
03/25/2010	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
03/25/2010	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
03/25/2010	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
03/25/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Immediate jeopardy to resident health or safety
03/25/2010	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
03/25/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
03/25/2010	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
03/25/2010	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
03/25/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
03/25/2010	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
03/25/2010	Make sure that residents are safe from serious medication errors.	Isolated	Actual harm
03/25/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
03/25/2010	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Minimal harm or potential for actual harm
03/25/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
03/25/2010	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
03/25/2010	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
03/25/2010	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Widespread	Minimal harm or potential for actual harm
03/25/2010	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Isolated	Minimal harm or potential for actual harm
03/25/2010	Make sure that nurse aides show they have the skills to be able to care for residents.	Widespread	Minimal harm or potential for actual harm
03/25/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
03/25/2010	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
10/05/2009	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
10/05/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
10/05/2009	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
10/05/2009	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
10/05/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
10/05/2009	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
10/05/2009	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
10/05/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
10/05/2009	proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Minimal harm or potential for actual harm
10/05/2009	no-smoking signs where oxygen is used.	Widespread	Minimal harm or potential for actual harm
10/05/2009	properly installed hallway dispensers for alcohol-based hand rub.	Widespread	Minimal harm or potential for actual harm
01/26/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
01/26/2009	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
01/26/2009	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
01/26/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/26/2009	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
01/26/2009	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
01/26/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/26/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
01/26/2009	post nurse staffing information.	Widespread	Potential for minimal harm
01/26/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
01/26/2009	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Isolated	Minimal harm or potential for actual harm
01/26/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
08/05/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
08/05/2008	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
08/05/2008	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
08/05/2008	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
08/05/2008	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
08/05/2008	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
08/05/2008	emergency showers.	Isolated	Minimal harm or potential for actual harm
08/05/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
11/15/2007	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.	Isolated	Minimal harm or potential for actual harm
11/15/2007	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
11/15/2007	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
11/15/2007	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
11/15/2007	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
11/15/2007	Hire a qualified activities director.	Pattern	Minimal harm or potential for actual harm
11/15/2007	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
11/15/2007	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
11/15/2007	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
11/15/2007	Provide clean bed and bath linens that are in good condition.	Isolated	Minimal harm or potential for actual harm
11/15/2007	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
11/15/2007	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
11/15/2007	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
11/15/2007	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
11/15/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
11/15/2007	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
11/15/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
11/15/2007	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
11/15/2007	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
11/15/2007	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
11/15/2007	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
11/15/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
11/15/2007	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
11/15/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
05/08/2007	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
05/08/2007	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
05/08/2007	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
05/08/2007	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
05/08/2007	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
05/08/2007	emergency showers.	Isolated	Minimal harm or potential for actual harm
05/08/2007	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