HERITAGE GARDENS OF SENATH MO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/15/2010	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
12/15/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/15/2010	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
12/15/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/15/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
12/15/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
12/15/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/15/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
12/15/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/15/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/15/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
12/15/2010	rooms that can be unlocked from inside without a key.	Pattern	Minimal harm or potential for actual harm
12/15/2010	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
01/07/2010	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
01/07/2010	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Minimal harm or potential for actual harm
01/07/2010	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
01/07/2010	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
01/07/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/07/2010	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
01/07/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Follow all laws and professional standards.	Widespread	Minimal harm or potential for actual harm
01/07/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
01/07/2010	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
01/07/2010	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
01/07/2010	no-smoking signs where oxygen is used.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
10/10/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/10/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
10/10/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
10/10/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
10/10/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
10/10/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
10/10/2008	proper exit design.	Isolated	Minimal harm or potential for actual harm
10/10/2008	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
10/10/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
10/10/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
10/10/2008	properly sized and located linen or trash receptacles.	Isolated	Minimal harm or potential for actual harm
10/10/2008	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
10/10/2008	emergency showers.	Pattern	Minimal harm or potential for actual harm
10/10/2008	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm

Have you or someone you know become a victim of nursing home abuse or neglect? If so, contact one of our experienced nursing home lawyers today. Help End Nursing Home Abuse

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