GOLDEN LIVINGCENTER - SORENSEN NE DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/28/2009	fire-resistant interior walls.	Widespread	Minimal harm or potential for actual harm
12/28/2009	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
12/28/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/28/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
12/28/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
12/28/2009	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
12/28/2009	proper backup exit lighting.	Widespread	Minimal harm or potential for actual harm
12/28/2009	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
12/28/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
12/28/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
12/28/2009	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
12/28/2009	restrictions on the use of portable space heaters.	Pattern	Minimal harm or potential for actual harm
12/28/2009	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
12/28/2009	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
12/28/2009	no-smoking signs where oxygen is used.	Pattern	Minimal harm or potential for actual harm
12/28/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
12/28/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
12/28/2009	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
12/28/2009	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
11/09/2009	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.	Pattern	Minimal harm or potential for actual harm
11/09/2009	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
11/09/2009	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
11/09/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/09/2009	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
11/09/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
11/09/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
11/09/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
11/09/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/15/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/15/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/15/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
10/15/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
10/15/2008	Hire enough skilled workers to carry out dietary service.	Pattern	Minimal harm or potential for actual harm
10/15/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
10/15/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
10/15/2008	Have enough outside airflow.	Pattern	Minimal harm or potential for actual harm
10/15/2008	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
10/15/2008	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
10/08/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
10/08/2008	proper backup exit lighting.	Widespread	Minimal harm or potential for actual harm
10/08/2008	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
10/08/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
10/08/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
10/08/2008	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
10/08/2008	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
10/08/2008	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
10/08/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
10/08/2008	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
10/31/2007	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
10/31/2007	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.	Pattern	Minimal harm or potential for actual harm
10/31/2007	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
10/31/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/31/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/31/2007	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
10/31/2007	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/31/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
10/31/2007	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/29/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
10/29/2007	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
10/29/2007	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm
10/29/2007	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
10/29/2007	properly sized and located linen or trash receptacles.	Widespread	Minimal harm or potential for actual harm
10/29/2007	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
10/29/2007	a separate and independent backup electrical power source.	Widespread	Minimal harm or potential for actual harm
10/29/2007	properly installed electrical wiring and equipment.	Widespread	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