cms_ND: 13

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
13 THE MEADOWS ON UNIVERSITY 355024 1315 S UNIVERSITY DR FARGO ND 58103 2019-05-16 641 D 1 1 FA2L11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.16), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Sets (MDSs) for 2 of 20 sampled residents (Resident #12 and #54). Failure to accurately complete Section A (Identification Information) and Section P (Restraints and Alarms) of the MDS does not allow each resident's assessment to reflect their current status/needs, and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION A: IDENTIFICATION INFORMATION The Long-Term Care Facility RAI Manual, revised (MONTH) (YEAR), page A-19 to A-20, stated, . Section A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions: Code 0, no: and skip to A1550, Conditions Related to ID/DD Status, if any of the following apply: PASRR Level I screening did not result in a referral for Level II screening, or Level II screening determined that the resident does not have a serious mental illness . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Coding instructions: Code A, Serious mental illness: if resident has been diagnosed with [REDACTED]. - Review of Resident #12's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The record showed a completed PASRR Level I and Level II screen for an indicated serious mental illness prior to Resident #12's admission to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed section A1500 coded No which resulted in a skipped coding pattern and staff failed to code section A1510 [NAME] Serious mental illness. SECTION P: RESTRAINTS AND ALARMS The Long-Term Care Facility RAI Manual, revised (MONTH) (YEAR), page P-1 to P-8, stated, . Prior to using any physical restraint, the nursing home must assess the resident to properly identify the resident's needs and the medical symptom(s) that the restraint is being employed to address. If a physical restraint is needed to treat the resident's medical symptom, the nursing home is responsible for assessing the appropriateness of that restraint. Bed rails used with residents who are immobile. If the resident is immobile and cannot voluntarily get out of bed because of a physical limitation or because proper assistive devices were not present, the bed rails do not meet the definition of a physical restraint. Coding instructions: Identify all physical restraints that were used at any time (day or night) during the 7-day look-back period. After determining whether or not an item listed in (P0100) is a physical restraint and was used during the 7-day look-back period, code the frequency of use: Code 0, not used: if the item was not used during the 7-day look-back or it was used but did not meet the definition. Code 1, used less than daily: if the item met the definition and was used less than daily. Code 2, used daily: if the item met the definition and was used on a daily basis during the look-back period. - Review of Resident #54's medical record occurred on all days of survey. [DIAGNOSES REDACTED]. The most recent quarterly MDS, dated [DATE], identified Resident #54 as cognitively intact. The current care plan stated, . Use of side rails to bed , (top rails only), for assistance with changing position due to bilateral shoulder pain related to severe arthritis. Review of the quarterly MDS, dated [DATE], showed section P0100 [NAME] Bed rail coded a 2 to indicate a restraint used daily during the look-back period. During an interview, on 05/15/19 at 11:20 a.m., an administrative nurse (#18) stated Resident #54's bed rails are used as an assistive device for bed mobility and agreed she coded the MDS incorrectly. 2020-09-01