VILLA ROSA NURSING HOME MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
10/06/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Potential for minimal harm
10/06/2009	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
10/06/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/06/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/06/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
10/06/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
09/17/2009	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
09/17/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
09/17/2009	resident room doors of proper design and width.	Pattern	Minimal harm or potential for actual harm
09/17/2009	exits that are free from obstructions and can be used at all times.	Pattern	Potential for minimal harm
11/10/2008	Let the resident refuse treatment or refuse to take part in an experiment.	Widespread	Immediate jeopardy to resident health or safety
11/10/2008	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
11/10/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
11/10/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/10/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
11/10/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
11/10/2008	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
11/10/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
11/10/2008	Make sure that a doctor approves a resident's admission in writing and that each resident has a doctor.	Pattern	Minimal harm or potential for actual harm
11/10/2008	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
11/10/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
11/10/2008	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
11/10/2008	Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
01/07/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
01/07/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/07/2008	properly working alarms on sprinkler valves.	Isolated	Minimal harm or potential for actual harm
10/12/2007	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
10/12/2007	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
10/12/2007	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
10/12/2007	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
10/12/2007	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
10/12/2007	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
10/12/2007	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Widespread	Potential for minimal harm
10/12/2007	Have enough outside airflow.	Widespread	Potential for minimal harm
10/12/2007	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
10/12/2007	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
08/13/2007	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
08/13/2007	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Potential for minimal harm
08/13/2007	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Potential for minimal harm
08/13/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
08/13/2007	a fire alarm system that can be heard throughout the facility.	Pattern	Potential for minimal harm
08/13/2007	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Potential for minimal harm
08/13/2007	an automatic smoke detection system in all hallways.	Pattern	Potential for minimal harm
08/13/2007	properly protected cooking facilities.	Pattern	Potential for minimal harm
08/13/2007	exits that are free from obstructions and can be used at all times.	Pattern	Potential for minimal harm
08/13/2007	proper medical gas storage and administration areas.	Pattern	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