HARBORSIDE NSG. & REHAB. CTR. MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/04/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Widespread	Minimal harm or potential for actual harm
02/04/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/04/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
02/04/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
02/04/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
02/04/2010	exit stairways and towers that are smoke proof.	Widespread	Minimal harm or potential for actual harm
02/04/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
02/04/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
02/04/2010	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
02/04/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Potential for minimal harm
02/04/2010	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
02/04/2010	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
02/04/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
02/04/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
02/04/2010	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
10/08/2009	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
10/08/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/08/2009	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
10/08/2009	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
10/08/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/08/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
10/08/2009	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
10/08/2009	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
10/08/2009	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.	Pattern	Minimal harm or potential for actual harm
10/08/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
10/08/2009	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
10/08/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
10/08/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/08/2009	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
10/08/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
03/23/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
03/23/2009	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Widespread	Minimal harm or potential for actual harm
03/23/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
03/23/2009	exit stairways and towers that are smoke proof.	Widespread	Minimal harm or potential for actual harm
03/23/2009	proper backup exit lighting.	Isolated	Minimal harm or potential for actual harm
03/23/2009	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
03/23/2009	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
03/23/2009	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
03/23/2009	restrictions on the use of portable space heaters.	Pattern	Minimal harm or potential for actual harm
03/23/2009	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
08/05/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
08/05/2008	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
08/05/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
08/05/2008	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
08/05/2008	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
08/05/2008	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
08/05/2008	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
08/05/2008	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
08/05/2008	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.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
08/05/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Pattern	Minimal harm or potential for actual harm
08/05/2008	Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) an adequate bed; 4) furniture that meets the resident's needs; or 5) enough closet space.	Widespread	Potential for minimal harm
08/05/2008	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Widespread	Potential for minimal harm
08/05/2008	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Give or get lab tests to meet the needs of residents.	Pattern	Minimal harm or potential for actual harm
08/05/2008	Give lab tests only when the attending doctor ordered them.	Pattern	Minimal harm or potential for actual harm
08/05/2008	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
08/05/2008	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
08/05/2008	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
08/05/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
08/05/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
09/21/2007	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.	Pattern	Minimal harm or potential for actual harm
09/21/2007	Send and promptly deliver unopened mail to residents.	Pattern	Minimal harm or potential for actual harm
09/21/2007	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
09/21/2007	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
09/21/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
09/21/2007	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
09/21/2007	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
09/21/2007	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	Isolated	Minimal harm or potential for actual harm
09/21/2007	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
09/21/2007	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
09/21/2007	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
09/21/2007	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
09/21/2007	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
09/21/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
09/21/2007	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
09/21/2007	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
09/21/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
09/21/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/21/2007	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Isolated	Minimal harm or potential for actual harm
09/21/2007	Give or get lab tests to meet the needs of residents.	Pattern	Minimal harm or potential for actual harm
09/21/2007	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
09/21/2007	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
07/14/2007	a fire alarm system that can be heard throughout the facility.	Pattern	Potential for minimal harm
07/14/2007	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Potential for minimal harm
07/14/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
07/14/2007	properly located and lighted "Exit" signs.	Pattern	Potential for minimal harm
07/14/2007	an automatic smoke detection system in all hallways.	Widespread	Potential for minimal harm
07/14/2007	properly maintained smoke detectors.	Widespread	Potential for minimal harm
07/14/2007	portable fire extinguishers.	Pattern	Potential for minimal harm
07/14/2007	exits that are free from obstructions and can be used at all times.	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