MID-ATLANTIC OF CHAPEL HILL, LLC MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/11/2010	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
06/11/2010	Keep adequate and comfortable lighting in all areas.	Widespread	Potential for minimal harm
06/11/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
06/11/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
05/06/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
05/06/2010	properly protected cooking facilities.	Pattern	Potential for minimal harm
05/06/2010	no-smoking signs where oxygen is used.	Widespread	Potential for minimal harm
05/06/2010	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
05/07/2009	a fire alarm system that can be heard throughout the facility.	Pattern	Potential for minimal harm
05/07/2009	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Potential for minimal harm
05/07/2009	properly protected cooking facilities.	Pattern	Potential for minimal harm
05/07/2009	properly constructed linen or trash chutes.	Pattern	Potential for minimal harm
05/07/2009	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
04/10/2009	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
04/10/2009	Protect the resident from a transfer or discharge that is not wanted or needed.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
04/10/2009	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
04/10/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
04/10/2009	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
04/10/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/18/2008	signs that state that exit doors are to be kept closed.	Pattern	Potential for minimal harm
07/18/2008	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
07/18/2008	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
07/18/2008	properly maintained smoke detectors.	Pattern	Potential for minimal harm
07/18/2008	properly constructed linen or trash chutes.	Pattern	Potential for minimal harm
07/18/2008	proper medical gas storage and administration areas.	Widespread	Potential for minimal harm
07/18/2008	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
02/21/2008	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
02/21/2008	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
02/21/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
02/21/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
02/21/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
02/21/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
02/21/2008	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	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