TENDERCARE CLARE MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
05/21/2010	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
05/21/2010	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
05/21/2010	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	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.	Isolated	Minimal harm or potential for actual harm
05/21/2010	Develop/implement required procedures for the administration of immunizations.	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.	Isolated	Minimal harm or potential for actual harm
05/21/2010	Properly mark drugs and other similar products.	Widespread	Minimal harm or potential for actual harm
05/21/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
05/20/2010	fire-resistant interior walls.	Pattern	Minimal harm or potential for actual harm
05/20/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
05/20/2010	proper stairway enclosures and vertical shafts.	Isolated	Minimal harm or potential for actual harm
05/20/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
05/20/2010	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
05/20/2010	did not have a written emergency evacuation plan.	Isolated	Minimal harm or potential for actual harm
05/20/2010	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
05/20/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
05/20/2010	restrictions on the use of flammable curtains.	Isolated	Minimal harm or potential for actual harm
05/20/2010	properly installed hallway dispensers for alcohol-based hand rub.	Widespread	Minimal harm or potential for actual harm
07/07/2009	resident room doors of proper design and width.	Isolated	Minimal harm or potential for actual harm
07/07/2009	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
07/07/2009	fire-resistant interior walls.	Pattern	Minimal harm or potential for actual harm
07/07/2009	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
07/07/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
07/07/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
07/07/2009	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
07/07/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/07/2009	exit stairways and towers that are smoke proof.	Pattern	Minimal harm or potential for actual harm
07/07/2009	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
07/07/2009	proper backup exit lighting.	Isolated	Minimal harm or potential for actual harm
07/07/2009	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
07/07/2009	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
07/07/2009	did not have a written emergency evacuation plan.	Isolated	Minimal harm or potential for actual harm
07/07/2009	an automatic smoke detection system in all hallways.	Pattern	Minimal harm or potential for actual harm
07/07/2009	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
07/07/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
07/07/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
07/07/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
07/02/2009	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
07/02/2009	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
07/02/2009	Keep sound levels comfortable.	Pattern	Minimal harm or potential for actual harm
07/02/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
07/02/2009	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
07/02/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
07/02/2009	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
07/02/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
07/02/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
07/02/2009	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Pattern	Minimal harm or potential for actual harm
07/25/2008	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Widespread	Potential for minimal harm
07/25/2008	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
07/25/2008	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
07/25/2008	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
07/25/2008	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
07/25/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Actual harm
07/25/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
07/25/2008	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
07/25/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
07/25/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
07/25/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
07/25/2008	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
07/25/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
07/25/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
07/25/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/25/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
07/25/2008	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
07/25/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
07/25/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
07/25/2008	properly installed electrical wiring and equipment.	Pattern	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