GRAND MANOR NURSING & REHABILITATION CENTER MO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
10/20/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
10/20/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/20/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/20/2009	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
10/20/2009	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
10/20/2009	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
10/20/2009	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
10/20/2009	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
10/20/2009	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
10/20/2009	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
09/10/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
09/10/2008	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
09/10/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
09/10/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
09/10/2008	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
09/10/2008	exit stairways and towers that are smoke proof.	Pattern	Minimal harm or potential for actual harm
09/10/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
09/10/2008	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	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.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Be administered in a way that leads to the highest possible level of well being for each resident.	Pattern	Actual harm
07/17/2007	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Minimal harm or potential for actual harm
07/17/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
07/17/2007	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
07/17/2007	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
07/17/2007	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
07/17/2007	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
07/17/2007	properly sized and located linen or trash receptacles.	Pattern	Minimal harm or potential for actual harm
07/17/2007	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
07/17/2007	no-smoking signs where oxygen is used.	Pattern	Minimal harm or potential for actual harm
07/17/2007	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
07/17/2007	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
07/17/2007	Let each resident choose whether to manage his or her own money or deposit it with the nursing home.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
07/17/2007	Have a private telephone available for use.	Pattern	Minimal harm or potential for actual harm
07/17/2007	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.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Minimal harm or potential for actual harm
07/17/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Keep safe, clean and homelike surroundings.	Widespread	Minimal harm or potential for actual harm
07/17/2007	Keep temperature levels comfortable and safe.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Keep sound levels comfortable.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
07/17/2007	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
07/17/2007	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
07/17/2007	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
07/17/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
07/17/2007	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
07/17/2007	Make sure that a resident does not become withdrawn, angry or depressed if these problems did not exist before.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Actual harm
07/17/2007	post nurse staffing information.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Make sure that all needed doctor visits are made personally by a doctor, as required.	Pattern	Potential for minimal harm
07/17/2007	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
07/17/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	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