PASADENA MANOR FL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
04/03/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility.	Isolated	Minimal harm or potential for actual harm
04/03/2009	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
04/03/2009	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
04/03/2009	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
04/03/2009	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
04/03/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
04/03/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
04/03/2009	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
04/03/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
04/03/2009	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
04/03/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
04/03/2009	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Keep a resident apart from the others if the resident has an infection that can spread.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
04/03/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
04/01/2009	restrictions on the use of flammable curtains.	Isolated	Minimal harm or potential for actual harm
04/01/2009	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
04/01/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
03/19/2008	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.	Widespread	Potential for minimal harm
03/19/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Actual harm
03/19/2008	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
03/19/2008	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Immediate jeopardy to resident health or safety
03/19/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
03/19/2008	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
03/19/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Actual harm
03/19/2008	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
03/19/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
03/19/2008	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
03/19/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
03/19/2008	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
03/19/2008	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Immediate jeopardy to resident health or safety
03/19/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
03/19/2008	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Widespread	Minimal harm or potential for actual harm
03/19/2008	Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Get rid of garbage properly.	Widespread	Minimal harm or potential for actual harm
03/19/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Be administered in a way that leads to the highest possible level of well being for each resident.	Pattern	Actual harm
03/04/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
03/04/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
02/21/2007	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
02/21/2007	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
02/21/2007	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
02/21/2007	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
02/21/2007	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
02/21/2007	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
02/21/2007	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
02/21/2007	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
02/21/2007	Keep sound levels comfortable.	Pattern	Minimal harm or potential for actual harm
02/21/2007	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/21/2007	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
02/20/2007	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
02/20/2007	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
02/20/2007	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
02/20/2007	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm

Have you or someone you know become a victim of nursing home abuse or neglect? If so, contact one of our experienced nursing home lawyers today. Help End Nursing Home Abuse

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