REGIS WOODS CARE AND REHABILITATION CENTER KY DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/03/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
05/27/2010	Make sure that private space is available in the nursing home for resident groups or residents' families to meet.	Pattern	Minimal harm or potential for actual harm
05/27/2010	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
05/27/2010	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
05/27/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
05/27/2010	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
05/27/2010	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm
02/26/2009	Have a private telephone available for use.	Isolated	Minimal harm or potential for actual harm
02/26/2009	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.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/26/2009	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.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
02/26/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
02/26/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
02/26/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
02/26/2009	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
02/26/2009	did not have a written emergency evacuation plan.	Pattern	Minimal harm or potential for actual harm
02/26/2009	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
02/26/2009	restrictions on the use of highly flammable materials.	Pattern	Minimal harm or potential for actual harm
02/26/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
03/20/2008	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
03/20/2008	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.	Isolated	Minimal harm or potential for actual harm
03/20/2008	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
03/20/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
03/20/2008	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
03/20/2008	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.	Isolated	Minimal harm or potential for actual harm
03/20/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
03/20/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
03/20/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
03/20/2008	Develop/implement required procedures for the administration of immunizations.	Widespread	Minimal harm or potential for actual harm
03/20/2008	Make sure that residents are well nourished.	Pattern	Potential for minimal harm
03/20/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
03/20/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
03/20/2008	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
03/20/2008	Put firmly secured handrails on each side of hallways.	Isolated	Minimal harm or potential for actual harm
03/20/2008	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
03/20/2008	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
03/18/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
03/18/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
03/18/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
03/18/2008	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
03/18/2008	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
03/18/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
03/18/2008	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
03/18/2008	proper facilities for the use and storage of combustible liquids.	Pattern	Minimal harm or potential for actual harm
03/18/2008	properly installed electrical wiring and equipment.	Widespread	Potential for minimal 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