RACELAND MANOR NURSING HOME, INC LA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/19/2010	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
11/19/2010	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
11/19/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
11/19/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
11/19/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
11/19/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
11/19/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
11/19/2010	outside doors or windows in every resident room.	Widespread	Potential for minimal harm
11/19/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
12/18/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
12/18/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/18/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
12/18/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
12/18/2009	corridors or aisles that are unobstructed and are at least 8 feet in width.	Isolated	Minimal harm or potential for actual harm
12/18/2009	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
12/18/2009	outside doors or windows in every resident room.	Widespread	Potential for minimal harm
12/18/2009	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
12/18/2009	fire safety features required by current fire safety codes.	Widespread	Minimal harm or potential for actual harm
12/18/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
12/18/2009	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
12/16/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
12/16/2009	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
12/16/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/16/2009	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Pattern	Minimal harm or potential for actual harm
12/16/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
12/16/2009	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
12/16/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/16/2009	Give or get lab tests to meet the needs of residents.	Pattern	Minimal harm or potential for actual harm
12/16/2009	Keep complete, dated lab records in the resident's file.	Pattern	Minimal harm or potential for actual harm
11/20/2008	Have a private telephone available for use.	Pattern	Minimal harm or potential for actual harm
11/20/2008	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
11/20/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
11/20/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
11/20/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
11/20/2008	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
11/20/2008	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Pattern	Minimal harm or potential for actual harm
11/20/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
11/20/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
11/20/2008	properly sized and located linen or trash receptacles.	Isolated	Minimal harm or potential for actual harm
11/20/2008	weekly inspections and monthly testing of generators.	Widespread	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