LOCHEARN NURSING HOME, LLC MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/04/2009	fire-resistant room wall surfaces.	Widespread	Potential for minimal harm
11/04/2009	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
11/04/2009	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Potential for minimal harm
11/04/2009	proper medical gas storage and administration areas.	Pattern	Potential for minimal harm
11/04/2009	no-smoking signs where oxygen is used.	Pattern	Potential for minimal harm
11/04/2009	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
08/07/2009	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
08/07/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
08/07/2009	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
08/07/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Potential for minimal harm
08/07/2009	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
08/07/2009	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
08/07/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
08/07/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
08/07/2009	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
08/07/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
08/07/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
08/07/2009	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Isolated	Minimal harm or potential for actual harm
08/07/2009	Provide rooms that are big enough for each resident.	Widespread	Minimal harm or potential for actual harm
08/07/2009	Follow all laws and professional standards.	Widespread	Potential for minimal harm
02/17/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Potential for minimal harm
02/17/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Potential for minimal harm
02/17/2009	exit stairways and towers that are smoke proof.	Pattern	Potential for minimal harm
02/17/2009	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
02/17/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
02/17/2009	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
02/17/2009	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
02/17/2009	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
06/13/2008	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Potential for minimal harm
06/13/2008	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
06/13/2008	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
06/13/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Give each resident enough fluids to keep them healthy and prevent dehydration.	Pattern	Minimal harm or potential for actual harm
06/13/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
06/13/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Provide rooms that are big enough for each resident.	Pattern	Minimal harm or potential for actual harm
06/13/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
11/09/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
11/09/2007	exit stairways and towers that are smoke proof.	Widespread	Potential for minimal harm
11/09/2007	properly located and lighted "Exit" signs.	Pattern	Potential for minimal harm
11/09/2007	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
11/09/2007	automatic sprinkler systems that have been maintained in working order.	Pattern	Potential for minimal harm
11/09/2007	portable fire extinguishers.	Pattern	Potential for minimal harm
11/09/2007	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Potential for minimal harm
11/09/2007	properly constructed linen or trash chutes.	Pattern	Potential for minimal harm
11/09/2007	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
11/09/2007	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
11/09/2007	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
05/03/2007	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
05/03/2007	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
05/03/2007	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
05/03/2007	Make sure that residents are well nourished.	Pattern	Potential for minimal harm
05/03/2007	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
05/03/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
05/03/2007	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
05/03/2007	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
05/03/2007	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
05/03/2007	Keep accurate and appropriate medical records.	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