MANOR AT ELFINDALE, THE MO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
07/13/2010	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	Actual harm
07/13/2010	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
07/13/2010	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
07/13/2010	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
07/13/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
07/13/2010	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
07/13/2010	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Pattern	Minimal harm or potential for actual harm
07/13/2010	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
07/13/2010	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
07/13/2010	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
07/13/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
07/13/2010	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
07/13/2010	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
07/13/2010	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Minimal harm or potential for actual harm
07/13/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
07/13/2010	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
07/13/2010	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
07/13/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
07/13/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
07/13/2010	properly located and lighted "Exit" signs.	Widespread	Minimal harm or potential for actual harm
07/13/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
07/13/2010	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
09/08/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
09/08/2009	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
09/08/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
09/08/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
09/08/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
09/08/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
09/08/2009	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm
09/08/2009	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
09/08/2009	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
07/18/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
07/18/2008	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
07/18/2008	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.	Pattern	Minimal harm or potential for actual harm
07/18/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/18/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
07/18/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
07/18/2008	record of quarterly fire drills for each shift under varying conditions.	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