VILLAGE SHALOM INC KS DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/30/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
12/30/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/30/2009	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
12/30/2009	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
12/30/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/30/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
12/30/2009	Give each resident enough fluids to keep them healthy and prevent dehydration.	Pattern	Minimal harm or potential for actual harm
12/30/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/30/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/30/2009	a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
09/30/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
09/30/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
09/30/2009	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
09/30/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
09/30/2009	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
10/24/2008	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Widespread	Potential for minimal harm
10/24/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
10/24/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Widespread	Potential for minimal harm
10/24/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/24/2008	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Widespread	Minimal harm or potential for actual harm
10/24/2008	Keep accurate and appropriate medical records.	Widespread	Potential for minimal harm
08/06/2008	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
08/06/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
08/06/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
08/06/2008	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
08/06/2008	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
08/06/2008	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
08/06/2008	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
08/06/2008	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
08/06/2008	emergency showers.	Pattern	Minimal harm or potential for actual harm
08/06/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
08/30/2007	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
08/30/2007	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
08/30/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
08/30/2007	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
08/30/2007	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
08/30/2007	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
05/10/2007	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
05/10/2007	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
05/10/2007	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
05/10/2007	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
05/10/2007	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
05/10/2007	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
05/10/2007	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
05/10/2007	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
05/10/2007	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
05/10/2007	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
05/10/2007	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
05/10/2007	weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
05/10/2007	properly installed electrical wiring and equipment.	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