TENDERCARE MARSHALL MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/15/2010	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
06/15/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
06/15/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
06/15/2010	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
06/11/2010	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Widespread	Potential for minimal harm
06/11/2010	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
06/11/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Potential for minimal harm
06/11/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
06/11/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
06/11/2010	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
06/11/2010	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
06/11/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Immediate jeopardy to resident health or safety
06/11/2010	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
06/11/2010	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
06/11/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
06/11/2010	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
06/11/2010	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
06/11/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
06/11/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
06/11/2010	Make sure that nurse aides show they have the skills to be able to care for residents.	Isolated	Minimal harm or potential for actual harm
06/11/2010	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
08/14/2009	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
08/14/2009	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
08/14/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
08/14/2009	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
08/14/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
08/14/2009	Provide clean bed and bath linens that are in good condition.	Pattern	Minimal harm or potential for actual harm
08/14/2009	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
08/14/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
08/14/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
08/14/2009	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
08/14/2009	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
08/14/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
08/14/2009	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
08/14/2009	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
08/14/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
08/14/2009	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
08/14/2009	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
08/14/2009	Have a program to keep infection from spreading.	Pattern	Potential for minimal harm
08/14/2009	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Pattern	Potential for minimal harm
08/14/2009	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Potential for minimal harm
08/13/2009	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
08/13/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
08/13/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
08/13/2009	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
08/13/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
08/13/2009	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
08/13/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
09/26/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
09/26/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
09/26/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
09/26/2008	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
09/26/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
09/26/2008	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Pattern	Potential for minimal harm
09/26/2008	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Potential for minimal harm
09/25/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
09/25/2008	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm

Have you or someone you know become a victim of nursing home abuse or neglect? If so, contact one of our experienced nursing home lawyers today. Help End Nursing Home Abuse

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