HILLCREST NURSING AND REHABILITATION COMMUNITY MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
10/15/2010	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
10/15/2010	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
10/15/2010	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Actual harm
10/15/2010	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
10/15/2010	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
10/15/2010	Keep adequate and comfortable lighting in all areas.	Isolated	Minimal harm or potential for actual harm
10/15/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/15/2010	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
10/15/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
10/15/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/15/2010	Get rid of garbage properly.	Widespread	Potential for minimal harm
10/15/2010	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
10/15/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/15/2010	Have enough outside airflow.	Isolated	Minimal harm or potential for actual harm
10/15/2010	Have licensed, certified, or registered staff to give needed services.	Isolated	Minimal harm or potential for actual harm
10/15/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
10/14/2010	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
10/14/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
10/14/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
10/14/2010	restrictions on the use of highly flammable materials.	Isolated	Minimal harm or potential for actual harm
10/14/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/14/2010	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
12/17/2009	Give the resident's legal representative the same rights as the resident.	Pattern	Minimal harm or potential for actual harm
12/17/2009	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
12/17/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
12/17/2009	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
12/17/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/17/2009	Screen residents when they are first admitted to send them to an area with special care for people with developmental disabilities or mental illness, if needed.	Pattern	Potential for minimal harm
12/17/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/17/2009	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
12/17/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
12/17/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/17/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/17/2009	Have enough backup water supply for important areas of the nursing home.	Widespread	Potential for minimal harm
12/17/2009	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Potential for minimal harm
12/17/2009	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
12/16/2009	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
12/16/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/16/2009	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
12/16/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
12/16/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
12/16/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
02/10/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
02/10/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
02/10/2009	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
02/10/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
02/10/2009	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
02/10/2009	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
02/10/2009	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
02/10/2009	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
02/05/2009	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
02/05/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
02/05/2009	Have a program to keep infection from spreading.	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