OXFORD HEALTH AND REHABILITATION CENTER MS DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
04/30/2010	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
04/30/2010	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
04/30/2010	Allow residents to easily see the results of the nursing home's most recent survey.	Isolated	Minimal harm or potential for actual harm
04/30/2010	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
04/30/2010	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.	Pattern	Minimal harm or potential for actual harm
04/30/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/30/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Immediate jeopardy to resident health or safety
04/30/2010	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
04/30/2010	post nurse staffing information.	Isolated	Minimal harm or potential for actual harm
04/30/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
04/30/2010	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
04/30/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
04/30/2010	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
04/30/2010	Be administered in a way that leads to the highest possible level of well being for each resident.	Isolated	Immediate jeopardy to resident health or safety
04/30/2010	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Minimal harm or potential for actual harm
04/30/2010	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
04/27/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
02/27/2009	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Isolated	Minimal harm or potential for actual harm
02/27/2009	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
02/27/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
02/27/2009	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
02/27/2009	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
02/27/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
02/27/2009	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
02/27/2009	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
02/25/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
02/25/2009	properly maintained smoke detectors.	Widespread	Potential for minimal harm
01/25/2008	Provide needed housekeeping and maintenance.	Widespread	Minimal harm or potential for actual harm
01/25/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Immediate jeopardy to resident health or safety
01/25/2008	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
01/23/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
01/23/2008	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
01/23/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
01/23/2008	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
01/23/2008	weekly inspections and monthly testing of generators.	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