MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER GA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/04/2010	Let residents complain without being treated differently or badly.	Isolated	Minimal harm or potential for actual harm
03/04/2010	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
03/04/2010	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
03/04/2010	Keep temperature levels comfortable and safe.	Pattern	Minimal harm or potential for actual harm
03/04/2010	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
03/04/2010	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
03/04/2010	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
03/04/2010	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
03/04/2010	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
03/04/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
03/04/2010	post nurse staffing information.	Widespread	Potential for minimal harm
03/04/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
03/04/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
03/04/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
03/04/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
03/04/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
03/04/2010	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
01/07/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Minimal harm or potential for actual harm
01/07/2009	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Minimal harm or potential for actual harm
01/07/2009	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
01/07/2009	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
01/07/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
01/07/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/07/2009	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
01/07/2009	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
11/08/2007	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
11/08/2007	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
11/08/2007	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
11/08/2007	Give professional services that follow each resident's written care plan.	Isolated	Actual harm
11/08/2007	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
11/08/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
11/08/2007	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
11/08/2007	Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion.	Isolated	Minimal harm or potential for actual harm
11/08/2007	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
11/08/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
11/08/2007	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
11/08/2007	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
11/08/2007	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
11/08/2007	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
11/08/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Potential for minimal harm
11/08/2007	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
11/08/2007	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
11/08/2007	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
11/08/2007	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
11/08/2007	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	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