SAINT MARY'S STANDISH COMMUNITY HOSPITAL MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
05/21/2010	Give the resident's legal representative the same rights as the resident.	Isolated	Minimal harm or potential for actual harm
05/21/2010	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
05/21/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
05/21/2010	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.	Pattern	Minimal harm or potential for actual harm
05/21/2010	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
05/21/2010	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
05/21/2010	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Isolated	Minimal harm or potential for actual harm
05/21/2010	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
05/21/2010	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
05/21/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
05/21/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
05/21/2010	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
07/13/2009	a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
07/13/2009	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
07/13/2009	proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Minimal harm or potential for actual harm
07/10/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Potential for minimal harm
07/10/2009	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
07/10/2009	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
07/10/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
07/10/2009	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.	Pattern	Minimal harm or potential for actual harm
07/10/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
07/10/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
07/10/2009	Make sure that doctors visit residents regularly, as required.	Pattern	Minimal harm or potential for actual harm
07/10/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
08/22/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
08/21/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
08/21/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
08/21/2008	a properly installed master alarm panel.	Isolated	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