STELLA MARIS, INC. MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
07/24/2009	fire-resistant room wall surfaces.	Pattern	Potential for minimal harm
07/24/2009	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
07/24/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
07/24/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
07/24/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
07/24/2009	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
07/24/2009	restrictions on the use of highly flammable materials.	Isolated	Minimal harm or potential for actual harm
07/24/2009	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
07/24/2009	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Minimal harm or potential for actual harm
07/24/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
07/24/2009	proper power supply for life support equipment.	Pattern	Potential for minimal harm
07/17/2009	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
07/17/2009	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
07/17/2009	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
07/17/2009	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
07/17/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
07/17/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
07/17/2009	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
07/17/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
07/17/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/17/2009	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
07/17/2009	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
07/17/2009	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
07/17/2009	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
07/17/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
08/26/2008	fire-resistant room wall surfaces.	Pattern	Potential for minimal harm
08/26/2008	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
08/26/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Potential for minimal harm
08/26/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
08/26/2008	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
08/26/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
08/26/2008	properly constructed linen or trash chutes.	Widespread	Potential for minimal harm
08/26/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
08/26/2008	proper fire barriers, ventilation and signs for the transport of oxygen.	Isolated	Minimal harm or potential for actual harm
08/26/2008	properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
06/19/2008	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
06/19/2008	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
06/19/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
06/19/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
06/19/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
06/19/2008	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
06/19/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
06/19/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Potential for minimal harm
06/19/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Potential for minimal harm
06/19/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
06/19/2008	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Widespread	Potential for minimal harm
06/19/2008	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
04/16/2007	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
04/16/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
04/16/2007	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
04/16/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
04/16/2007	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
04/16/2007	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
04/16/2007	Develop/implement required procedures for the administration of immunizations.	Pattern	Potential for minimal harm
04/16/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
04/16/2007	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
04/16/2007	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
04/16/2007	Store, cook, and give out food in a safe and clean way.	Pattern	Potential for minimal harm
04/16/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
04/16/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm
04/16/2007	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
04/16/2007	Give or get x-rays and other tests to meet the needs of residents.	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