SABAL PALMS HEALTH CARE CENTER FL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/18/2009	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.	Pattern	Potential for minimal harm
12/18/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
12/18/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/18/2009	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
12/18/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/18/2009	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
12/18/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
12/18/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/18/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
12/18/2009	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
12/18/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/18/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/15/2009	a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
12/15/2009	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Isolated	Minimal harm or potential for actual harm
11/06/2008	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
11/06/2008	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
11/06/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
11/06/2008	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
11/06/2008	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
11/06/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
11/06/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
11/06/2008	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
11/05/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm
11/05/2008	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
11/05/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
10/11/2007	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
10/11/2007	Protect each resident from all abuse, physical punishment, and being separated from others.	Pattern	Minimal harm or potential for actual harm
10/11/2007	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
10/11/2007	Provide care for each resident in a way that keeps or builds the resident's quality of life.	Pattern	Minimal harm or potential for actual harm
10/11/2007	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
10/11/2007	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
10/11/2007	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/11/2007	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
10/11/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/11/2007	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	Isolated	Minimal harm or potential for actual harm
10/11/2007	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
10/11/2007	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
10/11/2007	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/11/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/11/2007	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Pattern	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