WALDORF CENTER MD DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/15/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/15/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
12/15/2009	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
12/15/2009	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
12/15/2009	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
12/15/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/15/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
12/15/2009	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
12/15/2009	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
12/15/2009	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Pattern	Minimal harm or potential for actual harm
12/15/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/15/2009	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
12/15/2009	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
12/15/2009	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
12/15/2009	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
12/15/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/15/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
12/15/2009	Follow all laws and professional standards.	Widespread	Minimal harm or potential for actual harm
11/30/2009	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
11/30/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
11/30/2009	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
12/23/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Potential for minimal harm
12/23/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
12/23/2008	hallway or ground-level exits in all residents' rooms.	Pattern	Minimal harm or potential for actual harm
12/23/2008	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
12/23/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
10/30/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
10/30/2008	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
10/30/2008	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
10/30/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
10/30/2008	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
10/30/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
10/30/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/30/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/30/2008	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
10/30/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
10/30/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
10/30/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
10/30/2008	Offer other nutritional food to each resident who will not eat the food served.	Pattern	Minimal harm or potential for actual harm
10/30/2008	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
10/30/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/30/2008	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
10/30/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
05/12/2008	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
05/12/2008	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
05/12/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
05/12/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
05/12/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
05/12/2008	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
05/12/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Potential for minimal harm
05/12/2008	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
05/12/2008	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
05/12/2008	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
05/12/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
05/12/2008	Make sure that a doctor approves a resident's admission in writing and that each resident has a doctor.	Isolated	Minimal harm or potential for actual harm
05/12/2008	Have a program to keep infection from spreading.	Widespread	Potential for minimal harm
05/12/2008	Have enough outside airflow.	Widespread	Potential for minimal harm
05/12/2008	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
05/12/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
05/12/2008	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
05/12/2008	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
05/12/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
03/25/2008	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
03/25/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
03/25/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
03/25/2008	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
03/25/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
03/25/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
03/25/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
03/25/2008	proper medical gas storage and administration areas.	Isolated	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