PUEBLO SPRINGS REHABILITATION CENTER AZ DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/20/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/20/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
01/20/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
01/13/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
01/13/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
01/13/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
01/13/2010	Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home.	Pattern	Potential for minimal harm
01/13/2010	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
01/13/2010	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
01/13/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/13/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
01/13/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/13/2010	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
01/13/2010	Have licensed, certified, or registered staff to give needed services.	Isolated	Minimal harm or potential for actual harm
01/13/2010	Keep complete, dated lab records in the resident's file.	Isolated	Minimal harm or potential for actual harm
01/13/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
10/30/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
10/30/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
10/30/2008	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
10/30/2008	properly installed hallway dispensers for alcohol-based hand rub.	Pattern	Minimal harm or potential for actual harm
10/23/2008	Keep temperature levels comfortable and safe.	Isolated	Minimal harm or potential for actual harm
10/23/2008	Get doctor orders for the resident's immediate care when admitted.	Isolated	Minimal harm or potential for actual harm
10/23/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Potential for minimal harm
10/23/2008	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
10/23/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/23/2008	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
10/23/2008	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
10/23/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
10/11/2007	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
10/11/2007	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
10/11/2007	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
10/11/2007	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
10/11/2007	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
10/11/2007	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
10/05/2007	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/05/2007	Give professional services that meet a professional standard of quality.	Pattern	Potential for minimal harm
10/05/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/05/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/05/2007	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
10/05/2007	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
10/05/2007	Give or get lab tests to meet the needs of residents.	Pattern	Potential for minimal harm
10/05/2007	Set up or keep a group of people to review and ensure quality.	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