MEADOW BROOK REHABILITATION CENTRE & SUITES IN DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/16/2011	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
02/16/2011	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
02/16/2011	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
02/16/2011	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
02/16/2011	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
02/16/2011	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
02/16/2011	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
02/16/2011	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
02/16/2011	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
02/16/2011	restrictions on the use of portable space heaters.	Pattern	Potential for minimal harm
02/16/2011	proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Minimal harm or potential for actual harm
02/16/2011	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
02/16/2011	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
02/08/2011	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	Minimal harm or potential for actual harm
02/08/2011	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
02/08/2011	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
02/08/2011	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
02/08/2011	Keep safe, clean and homelike surroundings.	Widespread	Minimal harm or potential for actual harm
02/08/2011	Provide clean bed and bath linens that are in good condition.	Widespread	Minimal harm or potential for actual harm
02/08/2011	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
02/08/2011	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
02/08/2011	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
02/08/2011	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
02/08/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
02/08/2011	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
02/08/2011	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
02/08/2011	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
02/08/2011	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
02/08/2011	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
02/08/2011	Give or get x-rays and other tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
02/08/2011	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Pattern	Minimal harm or potential for actual harm
02/08/2011	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
04/26/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm
03/18/2010	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	Minimal harm or potential for actual harm
03/18/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
03/18/2010	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
03/18/2010	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
03/18/2010	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
03/18/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
03/18/2010	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
03/18/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
03/18/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
03/18/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
03/18/2010	Quickly tell the resident's doctor the results of x-rays and other tests.	Isolated	Minimal harm or potential for actual harm
05/14/2009	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
05/14/2009	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	Minimal harm or potential for actual harm
05/14/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
05/14/2009	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
05/14/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
05/14/2009	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
05/14/2009	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
05/14/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
05/14/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
05/14/2009	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
05/14/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
05/14/2009	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
05/14/2009	Hire enough skilled workers to carry out dietary service.	Pattern	Minimal harm or potential for actual harm
05/14/2009	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
05/14/2009	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
05/14/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
05/14/2009	Have a program to keep infection from spreading.	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