SOUNDVIEW SKILLED NURSING & REHABILITATION CT DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
08/30/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
08/30/2010	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
08/30/2010	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
08/30/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
08/30/2010	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
08/30/2010	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
08/30/2010	properly constructed linen or trash chutes.	Widespread	Minimal harm or potential for actual harm
08/30/2010	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
08/30/2010	fire safety features required by current fire safety codes.	Widespread	Minimal harm or potential for actual harm
08/30/2010	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Minimal harm or potential for actual harm
08/27/2010	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
08/27/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
08/27/2010	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
08/27/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
08/27/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
08/27/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
08/27/2010	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
08/27/2010	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
08/27/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
08/27/2010	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
08/27/2010	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
08/27/2010	Choose a doctor to be the medical director.	Isolated	Minimal harm or potential for actual harm
09/03/2009	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.	Pattern	Minimal harm or potential for actual harm
09/03/2009	Send and promptly deliver unopened mail to residents.	Widespread	Potential for minimal harm
09/03/2009	Protect residents from mistreatment, neglect, and/or theft of personal property.	Pattern	Immediate jeopardy to resident health or safety
09/03/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
09/03/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
09/03/2009	Listen to the resident or family groups or act on their complaints or suggestions.	Widespread	Potential for minimal harm
09/03/2009	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
09/03/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
09/03/2009	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
09/03/2009	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.	Pattern	Minimal harm or potential for actual harm
09/03/2009	Give professional services that meet a professional standard of quality.	Isolated	Actual harm
09/03/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Immediate jeopardy to resident health or safety
09/03/2009	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
09/03/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Actual harm
09/03/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
09/03/2009	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
09/03/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
09/03/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
09/03/2009	Have a program to keep infection from spreading.	Widespread	Immediate jeopardy to resident health or safety
09/03/2009	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
09/03/2009	Choose a doctor to be the medical director.	Widespread	Minimal harm or potential for actual harm
09/03/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
09/03/2009	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
09/03/2009	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
09/02/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
09/02/2009	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
09/02/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
09/02/2009	did not have a written emergency evacuation plan.	Pattern	Minimal harm or potential for actual harm
09/02/2009	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
09/02/2009	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
09/02/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
09/02/2009	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
09/02/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
09/02/2009	fire safety features required by current fire safety codes.	Widespread	Minimal harm or potential for actual harm
02/26/2009	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
02/26/2009	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Listen to the resident or family groups or act on their complaints or suggestions.	Isolated	Minimal harm or potential for actual harm
02/26/2009	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
02/26/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Keep adequate and comfortable lighting in all areas.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
02/26/2009	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
02/26/2009	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
02/26/2009	Give professional services that meet a professional standard of quality.	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	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
02/26/2009	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
02/26/2009	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	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/26/2009	Get rid of garbage properly.	Pattern	Potential for minimal harm
02/26/2009	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Potential for minimal harm
02/26/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
02/26/2009	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
02/26/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
02/26/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
02/26/2009	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Isolated	Minimal harm or potential for actual harm
02/19/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
02/19/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
02/19/2009	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
02/19/2009	properly installed electrical wiring and equipment.	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