WINTHROP MANOR LONGTERM CARE & REHAB CTR ME DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
10/17/2008	fire safety features required by current fire safety codes.	Pattern	Potential for minimal harm
10/17/2008	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
10/16/2008	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Potential for minimal harm
10/16/2008	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Minimal harm or potential for actual harm
10/16/2008	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
10/16/2008	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
10/16/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
10/16/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Potential for minimal harm
10/16/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/16/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
10/16/2008	Protect residents from mistreatment, neglect, and/or theft of personal property.	Widespread	Potential for minimal harm
10/16/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/16/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
12/21/2007	Let residents talk to and get information from agencies acting on their behalf.	Widespread	Potential for minimal harm
12/21/2007	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm
12/21/2007	Keep each resident's personal and medical records private and confidential.	Pattern	Potential for minimal harm
12/21/2007	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Potential for minimal harm
12/21/2007	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Widespread	Potential for minimal harm
12/21/2007	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	Actual harm
12/21/2007	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
12/21/2007	Tell the resident completely about his or her health status.	Pattern	Minimal harm or potential for actual harm
12/21/2007	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.	Pattern	Minimal harm or potential for actual harm
12/21/2007	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
12/21/2007	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
12/21/2007	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Widespread	Actual harm
12/21/2007	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
12/21/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
12/21/2007	Make sure that each residents' abilities to take care of themselves does not lessen, unless a change cannot be avoided.	Isolated	Actual harm
12/21/2007	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Actual harm
12/21/2007	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
12/21/2007	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Actual harm
12/21/2007	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.	Widespread	Actual harm
12/21/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
12/21/2007	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Potential for minimal harm
12/21/2007	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
12/21/2007	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Widespread	Minimal harm or potential for actual harm
12/21/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/21/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Minimal harm or potential for actual harm
12/21/2007	Choose a doctor to be the medical director.	Widespread	Actual harm
12/21/2007	1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator.	Widespread	Actual harm
12/21/2007	Follow all laws and professional standards.	Widespread	Minimal harm or potential for actual harm
12/21/2007	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Actual harm
10/19/2006	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.	Pattern	Minimal harm or potential for actual harm
10/19/2006	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
10/19/2006	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
10/19/2006	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
10/19/2006	Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection.	Pattern	Minimal harm or potential for actual harm
10/19/2006	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/19/2006	proper stairway enclosures and vertical shafts.	Widespread	Potential for minimal harm
10/19/2006	no-smoking signs where oxygen is used.	Pattern	Potential for minimal harm
10/19/2006	properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
10/19/2006	a two-hour-resistant firewall in common walls.	Widespread	Potential for minimal harm
10/19/2006	automatic sprinkler systems that have been maintained in working order.	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