TIMBERCREST CHURCH OF BRETHREN IN DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/17/2010	fire-resistant interior walls.	Widespread	Potential for minimal harm
03/17/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
03/17/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
03/17/2010	proper exit design.	Pattern	Minimal harm or potential for actual harm
03/17/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
03/17/2010	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
03/17/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Potential for minimal harm
03/17/2010	portable fire extinguishers.	Pattern	Potential for minimal harm
03/17/2010	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
03/17/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
03/17/2010	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Potential for minimal harm
03/17/2010	an approved back-up procedure for a faulty fire alarm system.	Widespread	Potential for minimal harm
03/12/2010	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
03/12/2010	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
04/15/2009	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
04/15/2009	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
04/15/2009	proper exit design.	Pattern	Minimal harm or potential for actual harm
04/15/2009	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
04/15/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
04/15/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
04/15/2009	an externally vented heating system.	Pattern	Minimal harm or potential for actual harm
04/15/2009	properly protected cooking facilities.	Pattern	Potential for minimal harm
04/15/2009	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
04/15/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
04/15/2009	properly installed hallway dispensers for alcohol-based hand rub.	Pattern	Minimal harm or potential for actual harm
05/09/2008	fire-resistant interior walls.	Pattern	Potential for minimal harm
05/09/2008	fire-resistant room wall surfaces.	Pattern	Potential for minimal harm
05/09/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
05/09/2008	proper backup exit lighting.	Pattern	Potential for minimal harm
05/09/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
05/09/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
05/05/2008	Make sure that the nursing home area is free of dangers that cause accidents.	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