MINNEOLA DISTRICT HOSPITAL LTCU KS DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/31/2010	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
03/31/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Widespread	Potential for minimal harm
03/31/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
03/31/2010	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
03/31/2010	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
03/31/2010	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
03/31/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
03/31/2010	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.	Pattern	Minimal harm or potential for actual harm
03/31/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
01/11/2010	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
01/11/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
01/11/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
01/11/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
01/11/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
01/22/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
01/22/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
12/05/2008	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.	Pattern	Minimal harm or potential for actual harm
12/05/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
12/05/2008	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
12/05/2008	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.	Pattern	Minimal harm or potential for actual harm
12/05/2008	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
12/05/2008	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
12/05/2008	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
12/05/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
12/05/2008	Give each resident enough fluids to keep them healthy and prevent dehydration.	Pattern	Minimal harm or potential for actual harm
12/05/2008	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
12/05/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
11/29/2007	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Widespread	Potential for minimal harm
11/29/2007	Properly mark drugs and other similar products.	Widespread	Minimal harm or potential for actual harm
11/20/2007	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
11/20/2007	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
11/20/2007	proper medical gas storage and administration areas.	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