ST LUKE COMMUNITY NURSING HOME MT DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/10/2010	post nurse staffing information.	Pattern	Potential for minimal harm
06/10/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Potential for minimal harm
06/10/2010	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
06/08/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
06/08/2010	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
06/08/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
06/08/2010	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
06/08/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
05/28/2009	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
05/28/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
05/28/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
05/28/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
05/28/2009	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
05/28/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
05/28/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
05/28/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
05/28/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
05/28/2009	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
05/28/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
05/28/2009	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
05/28/2009	proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm
05/28/2009	signs that state that exit doors are to be kept closed.	Pattern	Minimal harm or potential for actual harm
05/28/2009	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
05/28/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
05/28/2009	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
06/26/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
06/26/2008	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
06/24/2008	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
06/24/2008	a two-hour-resistant firewall in common walls.	Pattern	Minimal harm or potential for actual harm
06/24/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
06/24/2008	proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm
06/24/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
06/24/2008	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
06/24/2008	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
06/24/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
06/24/2008	back-up procedures in place for a faulty automatic sprinkler system.	Isolated	Minimal harm or potential for actual harm
06/24/2008	an approved back-up procedure for a faulty fire alarm system.	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