JEROLD PHELPS COMM HOSP SNF CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/26/2011	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
01/26/2011	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/26/2011	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/26/2011	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
01/26/2011	did not have a written emergency evacuation plan.	Isolated	Minimal harm or potential for actual harm
01/26/2011	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
01/26/2011	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
01/26/2011	restrictions on the use of portable space heaters.	Isolated	Minimal harm or potential for actual harm
01/26/2011	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
01/26/2011	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/26/2011	properly installed hallway dispensers for alcohol-based hand rub.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Keep each resident's personal and medical records private and confidential.	Widespread	Potential for minimal harm
01/13/2011	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Hire a qualified activities director.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
01/13/2011	post nurse staffing information.	Pattern	Potential for minimal harm
01/13/2011	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
01/14/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
01/14/2010	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
01/14/2010	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
01/14/2010	did not have a written emergency evacuation plan.	Isolated	Minimal harm or potential for actual harm
01/14/2010	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
01/14/2010	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
01/14/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
01/14/2010	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
01/14/2010	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
01/14/2010	properly constructed piped-in oxygen systems.	Widespread	Minimal harm or potential for actual harm
01/14/2010	a properly installed master alarm panel.	Widespread	Minimal harm or potential for actual harm
01/14/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
01/06/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
11/18/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
11/18/2008	properly maintained smoke detectors.	Widespread	Potential for minimal harm
11/18/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
11/18/2008	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
11/05/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
11/05/2008	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
11/05/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
11/05/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
11/05/2008	Store, cook, and give out food in a safe and clean way.	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