TENDERCARE SAGINAW MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/28/2011	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
01/28/2011	Have a private telephone available for use.	Isolated	Minimal harm or potential for actual harm
01/28/2011	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
01/28/2011	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Isolated	Minimal harm or potential for actual harm
01/28/2011	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
01/28/2011	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
01/28/2011	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
01/28/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/28/2011	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Pattern	Minimal harm or potential for actual harm
01/28/2011	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
01/28/2011	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
01/28/2011	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
01/28/2011	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
01/28/2011	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Minimal harm or potential for actual harm
01/28/2011	Keep complete, dated lab records in the resident's file.	Pattern	Minimal harm or potential for actual harm
01/28/2011	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Pattern	Minimal harm or potential for actual harm
01/28/2011	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
01/27/2011	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/27/2011	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
01/27/2011	protected exits that allow the resident to escape the building.	Pattern	Minimal harm or potential for actual harm
01/27/2011	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
01/27/2011	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
01/27/2011	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Give the resident's legal representative the same rights as the resident.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Keep safe, clean and homelike surroundings.	Widespread	Minimal harm or potential for actual harm
04/09/2010	Provide needed housekeeping and maintenance.	Widespread	Minimal harm or potential for actual harm
04/09/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Develop a plan with the resident and family for the resident's care after leaving the nursing home.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Minimal harm or potential for actual harm
04/09/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
04/09/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
04/09/2010	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
04/09/2010	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
04/09/2010	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Widespread	Potential for minimal harm
04/07/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
04/07/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
04/07/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
04/07/2010	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
04/07/2010	corridors or aisles that are unobstructed and are at least 8 feet in width.	Isolated	Minimal harm or potential for actual harm
04/07/2010	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
04/07/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
04/07/2010	properly working sprinkler alarm system.	Widespread	Minimal harm or potential for actual harm
04/07/2010	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
04/07/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
04/07/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
04/07/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
04/07/2010	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
04/07/2010	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
05/20/2009	Give the resident's legal representative the same rights as the resident.	Pattern	Potential for minimal harm
05/20/2009	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
05/20/2009	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
05/20/2009	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
05/20/2009	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
05/20/2009	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
05/20/2009	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
05/20/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
05/20/2009	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
05/20/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
05/20/2009	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
05/20/2009	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
05/20/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
05/20/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
05/20/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
05/20/2009	Offer other nutritional food to each resident who will not eat the food served.	Isolated	Minimal harm or potential for actual harm
05/20/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
05/20/2009	Get rid of garbage properly.	Pattern	Minimal harm or potential for actual harm
05/20/2009	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
05/20/2009	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Minimal harm or potential for actual harm
05/20/2009	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
05/19/2009	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
05/19/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
05/19/2009	corridors or aisles that are unobstructed and are at least 8 feet in width.	Isolated	Minimal harm or potential for actual harm
05/19/2009	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
05/19/2009	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