TRANSITIONAL HEALTH SVCS OF FREMONT MI DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
05/28/2010	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Minimal harm or potential for actual harm
05/28/2010	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
05/28/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
05/28/2010	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
05/28/2010	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
05/27/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
05/27/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
05/27/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
05/27/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
05/27/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
05/27/2010	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
05/27/2010	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
07/17/2009	Give the resident's legal representative the same rights as the resident.	Isolated	Minimal harm or potential for actual harm
07/17/2009	Keep each resident's personal and medical records private and confidential.	Pattern	Potential for minimal harm
07/17/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
07/17/2009	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
07/17/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
07/17/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	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	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
07/17/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/17/2009	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
07/17/2009	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
07/17/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
07/17/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
07/17/2009	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
07/17/2009	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
07/15/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
07/15/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/15/2009	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
07/15/2009	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
07/15/2009	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
07/15/2009	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
07/15/2009	properly installed hallway dispensers for alcohol-based hand rub.	Widespread	Minimal harm or potential for actual harm
07/15/2009	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
08/04/2008	fire-resistant room wall surfaces.	Widespread	Minimal harm or potential for actual harm
08/04/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
08/04/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
08/04/2008	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
08/04/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
08/04/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
08/04/2008	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
08/04/2008	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
08/04/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
08/04/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
08/04/2008	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
08/04/2008	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
08/01/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
08/01/2008	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
08/01/2008	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
08/01/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
08/01/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
08/01/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
08/01/2008	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
08/01/2008	Have enough backup water supply for important areas of the nursing home.	Widespread	Potential for minimal 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