MARCUS DALY MEM HOSP TCU MT DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/05/2010	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
01/05/2010	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
01/05/2010	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
01/05/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
02/19/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
02/19/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Widespread	Potential for minimal harm
02/19/2009	post nurse staffing information.	Widespread	Potential for minimal harm
02/19/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Widespread	Potential for minimal harm
02/19/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
02/19/2009	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Potential for minimal harm
02/19/2009	Keep accurate and appropriate medical records.	Widespread	Potential for minimal harm
02/19/2009	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Minimal harm or potential for actual harm
02/19/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
02/19/2009	emergency lighting that can last at least 1 1/2 hours.	Widespread	Potential for minimal harm
02/19/2009	did not have a written emergency evacuation plan.	Widespread	Potential for minimal harm
02/19/2009	portable fire extinguishers.	Pattern	Potential for minimal harm
02/19/2009	properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
02/19/2009	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Potential for minimal harm
02/19/2009	an approved back-up procedure for a faulty fire alarm system.	Widespread	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