JUNIPER VILLAGE - THE SPEARLY CENTER CO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/08/2010	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
01/08/2010	a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
01/08/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
01/08/2010	fire-resistant interior walls.	Isolated	Minimal harm or potential for actual harm
01/08/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/08/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
01/08/2010	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
01/08/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
01/08/2010	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
01/08/2010	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
01/08/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
01/08/2010	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
01/08/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
01/08/2010	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
01/08/2010	weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
01/08/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
01/08/2010	back-up procedures in place for a faulty automatic sprinkler system.	Isolated	Minimal harm or potential for actual harm
01/08/2010	an approved back-up procedure for a faulty fire alarm system.	Isolated	Minimal harm or potential for actual harm
01/08/2010	an elevator that firefighters can control in the event of a fire.	Widespread	Minimal harm or potential for actual harm
12/23/2009	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Isolated	Minimal harm or potential for actual harm
12/23/2009	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
12/23/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
12/23/2009	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
12/23/2009	Provide care for each resident in a way that keeps or builds the resident's quality of life.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Actual harm
12/23/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
12/23/2009	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
12/23/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
12/23/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/23/2009	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
11/06/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
11/06/2008	proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm
11/06/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
11/06/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
11/06/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
11/06/2008	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
11/06/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
11/06/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
11/06/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Give the resident's legal representative the same rights as the resident.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual 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	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Actual harm
10/10/2008	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	Actual harm
10/10/2008	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
10/10/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/10/2008	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
10/10/2008	Keep assessments completed in the preceding 15 months in the resident's active record.	Widespread	Minimal harm or potential for actual harm
10/10/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
10/10/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/10/2008	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
10/10/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Have licensed, certified, or registered staff to give needed services.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
11/28/2007	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
11/01/2007	Provide care for each resident in a way that keeps or builds the resident's quality of life.	Pattern	Minimal harm or potential for actual harm
11/01/2007	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
11/01/2007	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
11/01/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
11/01/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
11/01/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
11/01/2007	Provide food in a way that meets a resident's needs.	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