MATHER NURSING CENTER MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/18/2010	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Actual harm
11/18/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
11/18/2010	Keep adequate and comfortable lighting in all areas.	Pattern	Minimal harm or potential for actual harm
11/18/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/18/2010	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
11/18/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
11/18/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
11/18/2010	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
11/18/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
11/18/2010	post nurse staffing information.	Widespread	Potential for minimal harm
11/18/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
11/18/2010	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
11/18/2010	Have enough backup water supply for important areas of the nursing home.	Widespread	Potential for minimal harm
11/18/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
11/18/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
11/18/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/07/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/06/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
01/06/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
12/11/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
12/11/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/10/2008	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.	Widespread	Potential for minimal harm
12/10/2008	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
12/10/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
12/10/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
12/10/2008	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
12/10/2008	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	Isolated	Actual harm
12/10/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
12/10/2008	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
12/10/2008	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
12/10/2008	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
12/10/2008	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
12/10/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
12/10/2008	post nurse staffing information.	Pattern	Potential for minimal harm
12/10/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/10/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
12/10/2008	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
12/10/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Potential for minimal harm
12/10/2008	Follow all laws and professional standards.	Pattern	Minimal harm or potential for actual harm
12/10/2008	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Isolated	Minimal harm or potential for actual harm
12/10/2008	Keep accurate and appropriate medical records.	Pattern	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