LAKELAND CENTER (THE) MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/18/2011	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
01/18/2011	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
01/18/2011	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
01/18/2011	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/18/2011	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
01/18/2011	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
01/18/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
01/18/2011	Get rid of garbage properly.	Pattern	Potential for minimal harm
01/18/2011	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm
01/18/2011	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
01/18/2011	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
01/13/2011	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
01/13/2011	signs that state that exit doors are to be kept closed.	Pattern	Minimal harm or potential for actual harm
01/13/2011	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
01/13/2011	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/13/2011	protected exits that allow the resident to escape the building.	Widespread	Minimal harm or potential for actual harm
01/13/2011	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
01/13/2011	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
01/13/2011	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
01/13/2011	a separate and independent backup electrical power source.	Widespread	Minimal harm or potential for actual harm
01/29/2010	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
01/29/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/29/2010	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
01/29/2010	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
01/28/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/28/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
01/28/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/28/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
01/28/2010	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
01/28/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
01/28/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
01/28/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
01/28/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
01/28/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
02/20/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
02/20/2009	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
02/20/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
02/20/2009	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
02/20/2009	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
02/20/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
02/20/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
02/20/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
02/20/2009	Hire enough skilled workers to carry out dietary service.	Isolated	Minimal harm or potential for actual harm
02/20/2009	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
02/20/2009	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
02/19/2009	proper stairway enclosures and vertical shafts.	Isolated	Minimal harm or potential for actual harm
02/19/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
02/19/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
02/19/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
02/19/2009	properly installed electrical wiring and equipment.	Isolated	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