Department of Health and Human Services
OFFICE OF
INSPECTOR GENERAL
Nursing Home Survey and Certification:
Deficiency Trends
JUNE GIBBS BROWN
Inspector General
MARCH 1999
OEI-02-98-00331 OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to
protect the integrity of the Department of Health and Human Services programs as well as the
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The
Inspector General informs the Secretary of program and management problems and recommends
legislative, regulatory, and operational approaches to correct them.
Office of Evaluation and Inspections
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of
Inspector General.  It conducts short-term management and program evaluations (called
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The
inspection reports provide findings and recommendations on the efficiency, vulnerability, and
effectiveness of departmental programs.  
OEI's New York Regional Office prepared this report under the direction of John I. Molnar,
Regional Inspector General and Renee C. Dunn, Deputy Regional Inspector General.  Principal
OEI staff included:
REGION HEADQUARTERS
Lucille Cop, RN Susan Burbach, Program Specialist
Danielle Fletcher
Daniel Ginsberg
Steve Shaw
Patricia Banta, RN intern
To obtain copies of this report, please call the New York Regional Office at (212) 264-2000.
Reports are also available on the World Wide Web at our home page address:
http://www.dhhs.gov/progorg/oei E X E C U T I V E    S U M M A R Y
PURPOSE
To describe deficiency trends indicated by survey data and the extent to which these trends
indicate quality of care in nursing homes. 
BACKGROUND
While many studies indicate that changes in law and regulations may have had a positive
effect on improving the environment and overall health care of nursing home residents,
recent reports by the Health Care Financing Administration and the General Accounting
Office have raised serious concerns about residents care and well-being.  The Senate
Special Committee on Aging held hearings in the summer of 1998 on these results.  At the
same time, the Office of Inspector General undertook a series of studies aimed at assessing
the quality of care in nursing homes.  
The 1987 Nursing Home Reform Act introduced an increased focus on the quality of life
and care, the importance of the individual resident, and the need to help the Medicare and
Medicaid nursing home residents reach the highest practicable level of functioning. 
Enforcement policies were established that gave the Health Care Financing Administration
the authority to impose a variety of corrective measures when a facility is not in substantial
compliance with the requirements for participation in the Medicare and/or Medicaid
program.   
This report examines trends in the Online Survey Certification and Reporting System
(OSCAR) data that indicate quality of care problems in nursing homes survey and
certification programs. A companion report describes the overall capacity of the State
survey and certification program to monitor quality of care in nursing homes.  Other OIG
reports address the trend in reported abuse in nursing home residents and  the role of the
ombudsman in protecting nursing home residents.
We selected a purposive sample of ten States: New York, California, Texas, Ohio, Illinois,
Pennsylvania, Massachusetts, Florida, New Jersey, and Tennessee.  We analyzed OSCAR
data in these States to identify trends in the amount and nature of deficiencies in nursing
home quality of care.  To better understand the overall context of these deficiencies, we
conducted structured interviews with the State director and surveyors.   
1
Survey and Certification: Deficiency Trends OEI-02-98-00331 FINDINGS
Overall Deficiencies Are Decreasing, but Quality of Care Deficiencies Are
Increasing and Other Serious Deficiencies Persist at High Levels
Deficiencies are classified into 17 major categories containing 185 subcategories of
specific deficiencies.  If a nursing home has deficiencies in three specific categories,  it  is
considered to have substandard quality of care, for enforcement purposes, depending on
the scope and severity.  The three categories are: quality of care, resident behavior and
facility practices, and quality of life.
While almost all deficiencies have declined over the past four surveys, substandard quality
of care deficiencies have decreased at a slower rate than all others. The 49 substandard
quality of care deficiencies have decreased by only 14 percent over the last four standard
surveys compared to a decrease of 32 percent for the other 136 deficiencies which do not
fall into the substandard quality of care categories. 
Although in total, substandard quality of care deficiencies have decreased, the
subcategory quality of care has increased.  Thirteen of the 25 deficiencies in the quality
of care subcategory are higher on the current survey than they were three surveys prior. 
Some noteworthy deficiency increases include the failure to provide range of motion
treatment, lack of adequate supervision or devices to prevent accidents, and catheterizing
residents without clinical need.  Additionally, three of those 13 have increased in every
survey over the past four standard surveys. 
Although some deficiencies have declined over the years, the number of deficiencies that
continue to be cited remains a cause for concern. For example,  pressure sores are bruises
or open sores on the skin which could be an indication that other kinds of problems are
occurring such as urinary incontinence, malnutrition or dehydration.  If a resident has a
cognitive loss or dementia, or  physical restraints, or psychotropic drugs are being used, 
the resident is vulnerable to resultant pressure sores. 
  
Nursing Homes with Chronic Quality of Care Problems Exist
 
The OSCAR data identifies some nursing homes that continue to have the same
deficiencies every survey.  Four hundred and sixty three nursing homes have been cited
with the same deficiencies over the past four contiguous surveys, representing 6 percent of
all homes in the sample States.  Nursing homes with serious deficiencies or constant non-
compliance issues are considered to have chronic quality of care problems. 
State survey and certification directors and surveyors describe circumstances similar to
what the OSCAR data show.  They cite that the percentage of nursing homes with these
problems is between one and 20 percent of all homes in their respective States.  Half of
2
Survey and Certification: Deficiency Trends OEI-02-98-00331 the State directors mention pressure sores and nutrition issues as frequent chronic quality
of care problems in their nursing homes.  The OSCAR data show the deficiency that
occurs the most frequently, both in our sample States and nationally, is the failure to give
proper treatment to prevent or treat pressure sores.  Surveyors concur with directors;
most also mention that staffing shortages and inferior staff proficiency levels precipitate
chronic quality of care in nursing homes.
State Directors and Surveyors Express Reservations about Relying Exclusively
on Oscar Data to Identify and Understand Problems in Nursing Homes 
Most surveyors and more than half of directors are satisfied with OSCAR data but
propose changes.  OSCAR data may not catch all the problems that exist in a nursing
home due to the current survey process.  Surveyors visit most facilities only once a year
and cannot be cognizant of problems that occur throughout the year.  Surveyors suggest
using OSCAR data in conjunction with other tools to obtain an accurate view of quality of
care.
The majority of the State survey and certification directors and surveyors we interviewed
believe that certain deficiencies have unclear definitions.  They note some specific
deficiencies that are open to individual interpretation and discretion.  Of the 17 categories,
those that are considered most problematic are resident rights, resident behavior and
facility practices, quality of life, quality of care, and nursing services. 
 
RECOMMENDATION
The resident-centered long-term care requirements of the nursing home survey are
essential tp guarantee the quality of care in nursing homes.  Clearly some major problems
need to be addressed.  Our findings support and elaborate on the Health Care Financing
Administrations initiative to strengthen the enforcement efforts by: 
  < making them more timely and effective,
  < changing the survey schedule to make surveys more unpredictable, 
  < increasing the number of night and weekend surveys,
  < increasing the number of surveys at nursing homes with chronic quality of care
problems, and 
  < focusing on specific problems such as pressure sores, dehydration, and
malnutrition.
 
These initiatives, if carried out completely, appear to be responsive to most of the
problems in this report as well as our companion report Nursing Home Survey and
Certification: Overall Capacity.
Many of the most frequently cited deficiencies are directly related to reported shortage of
3
Survey and Certification: Deficiency Trends OEI-02-98-00331 direct care staff.  The failure to provide proper treatment to prevent or treat pressure sores
illustrates the lack of direct care staff to assure that residents are properly hydrated,
nourished and turned frequently.  In light of our findings in this report, additional action is
needed.  We recommend that the Health Care Financing Administration: 
  < develop staffing standards for registered nurses and certified nurse assistants in
nursing homes to assure sufficient staff on all shifts to enable residents to have
proper care.  Staffing standards should account for the intensity of care needed,
qualifications of the staff, and the specific characteristics of both the nursing home
and the residents.
 AGENCY COMMENTS
We received comments on the draft report from HCFA and the Assistant Secretary for
Planning and Evaluation (ASPE).  The HCFA concurs with our recommendations.  The
ASL informally commented on the reports, and we made the appropriate changes.
The ASPE expressed some concern about the ability of OSCAR data to assess quality of
care in nursing homes.  We recognize the limitations of OSCAR but used it as only one
indicator of quality. We are happy to re-emphasize here what we say in our report that
OSCAR data should not be looked at independently.  In this report we used it in
combination with the views of nursing home surveyors and State Directors.
4
Survey and Certification: Deficiency Trends OEI-02-98-00331 T A B L E    O F    C O N T E N T S
PAGE
EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
FINDINGS
Deficiency Trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Chronic Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
 
Data Accuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
RECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
APPENDICES
A: Substandard Quality of Care Deficiencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
B: Deficiency Tags . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
C: Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
5
Survey and Certification: Deficiency Trends OEI-02-98-00331 I N T R O D U C T I O N
PURPOSE
To describe deficiency trends indicated by survey data and the extent to which these trends
indicate quality of care in nursing homes. 
BACKGROUND
While many studies indicate that changes in law and regulations may have had a positive
effect on improving the environment and overall health care of nursing home residents,
recent reports by the Health Care Financing Administration (HCFA) and the General
Accounting Office have raised serious concerns about residents care and well-being.  The
Senate Special Committee on Aging held hearings in the summer of 1998 on these results. 
At the same time, the Office of Inspector General undertook additional studies aimed at
assessing the quality of care in nursing homes.  Among these were studies on prescription
drug utilization, patient abuse, and criminal background on employees.  This report
examines trends in the Online Survey Certification and Reporting System (OSCAR) data
that indicate quality of care problems in nursing homes survey and certification data. A
companion report describes the overall capacity of the State survey and certification
program to monitor quality of care in nursing homes.  Future OIG reports will address the
trend in reported abuse in nursing home residents, the role of the ombudsman, and the
availability of nursing home survey results.
Generally, a nursing home is a residential facility offering daily living assistance to
individuals who are physically or mentally unable to live independently.  Residents are
provided rooms, meals, assistance with daily living, and in most cases, some medical
treatment for those who require it.  Medicare can help pay for skilled nursing facility
(SNF) care for up to 100 days in a benefit period when a beneficiary meets certain
conditions.  Medicaid coverage varies among States.  Medicaid eligible beneficiaries who
require custodial care such as help with eating, bathing, taking medicine and toileting, as
well as those who require skilled care may have nursing home stay paid for by Medicaid. 
Medicaid payments to nursing homes in 1996 totaled $29.6 billion.  In 1989 Medicare paid
$2.8 billion to nursing homes, an amount totaling 4.7 percent of the Medicare budget.  In
1996 this amount had increased to $10.6 billion, totaling 9 percent of the Medicare
budget.
In 1986 the Institute of Medicine conducted a study on nursing home regulation. The
Institute reported prevalent problems regarding the quality of care for nursing home
residents and the need for stronger Federal regulations.  In 1987 the General Accounting
6
Survey and Certification: Deficiency Trends OEI-02-98-00331 Office (GAO) reported that over one third of nursing homes were operating below the
Federal minimum standards.  These reports, along with widespread concern regarding
nursing home conditions, persuaded Congress to pass the Omnibus Budget Reconciliation
Act of 1987 (OBRA 1987).  As a part of OBRA 1987, Congress passed the
comprehensive Nursing Home Reform Act (PL 100-203).  These actions expanded
requirements that nursing facilities had to comply with prior to Medicare certification. 
The Nursing Home Reform Act also ceded personal rights to nursing home residents such
as the right to be free of physical or mental abuse, and the right to be free from chemical
and physical restraints.  It also altered the principles for enforcement of Federal standards
of care in nursing homes.
Medicare Requirements
The Health Care Financing Administration (HCFA) has the responsibility to act as
prudent purchaser by ensuring that nursing homes participating in Medicare and/or
Medicaid meet certain requirements for quality environment and services.  These
requirements are found at 42 Code of Federal Regulations (CFR) Part 483, Subpart B. 
The OBRA 1987, as amended in 1988, 1989, and 1990, changed these requirements by
introducing an increased focus on the quality of life and care, the importance of the
individual resident, and the need to help the resident reach the highest practicable level
of functioning.  It also included interviewing and assessing residents rather than simply
reviewing medical records.  
Enforcement Procedures
The 1987 Nursing Home Reform Act enforcement provisions were enacted when the
State Operations Manual (SOM) became effective on July 1, 1995.  The HCFA had
several process goals during the implementation of the new survey and enforcement
systems.  The first was to promote consistency through extensive training, the second was
to link appropriate remedies to deficiencies, and the third was to avoid unnecessary
procedures.  Congress recognized that one enforcement response would not be
appropriate for all deficiencies.  Enforcement policies were established that gave HCFA
the license to impose a variety of corrective measures when a facility is not in substantial
compliance with the requirements for participation in the Medicare and/or Medicaid
program.  Some options include temporary management, denial of payment for new
admissions, civil money penalties, termination of the facility, or State monitoring of the
facility.  States are responsible for establishing their own remedy guidelines.
The HCFA imposed a number of administrative changes on enforcement procedures
following the implementation of the State Operations Manual.  In June of 1995, HCFA
enacted a temporary moratorium on the collection of certain lower-level money penalties
(CMPs).  The moratorium preceded HCFAs decision to alter the State Operations
Manual in December of 1996.  Civil monetary penalties are now limited to situations of
7
Survey and Certification: Deficiency Trends OEI-02-98-00331 immediate jeopardy or to nursing facilities that are poor performers or have serious
deficiencies that are not corrected at the time of a revisit.  Additional changes by HCFA
redefined the scope of deficiencies, permitted States to avoid revisits in facilities that have
lower level deficiencies, and established new terms to define facilities that are not in
substantial compliance. 
Requirements of Surveys
An important characteristic of nursing homes is their Federal certification status for the
Medicare and/or Medicaid programs.  While some nursing homes may not meet
certification requirements, or may elect not to participate in either program, nearly all
nursing homes had some form of certification in 1996.  The Nursing Home Reform Act
defines the State survey and certification process for determining nursing home
compliance with the Federal standards.
To ensure acceptable compliance, both the State for Medicaid facilities, and HCFA for
Medicare facilities, are responsible for performing routine facility surveys.  For those
facilities designated as dually-certified, HCFA has the primary responsibility.  The HCFA
contracts with States to perform the surveys for Medicare and dually-certified nursing
homes.  The survey process determines, and the resulting survey documentation records
(HCFA-2567), the compliance or noncompliance of the facilities.  When a facility fails to
meet a specific requirement, a deficiency or citation is given to the facility by the
surveyors.  Surveyors provide the reasons justifying any resulting enforcement action and
the record on which to defend that action in the appeals process.  Surveyors are instructed
to use the Principles of Documentation when determining the extent of non-compliance. 
Generally, there are 20 principles that should be considered in the citation of deficiencies
on the HCFA-2567.  These principals are generic and apply to the documentation of
survey outcomes regardless of the program (Medicare/Medicaid). 
As a result of the Nursing Home Reform Act, a new survey and certification process was
implemented in 1995.  All nursing facilities are now subject to an unannounced standard
survey no later than 15 months after the date of the previous standard survey, and the
Statewide average interval between standard surveys must be 12 months or less, creating
a Federal standard survey window between 9 and 15 months.  Each standard survey
includes a stratified case mix of nursing home residents measuring medical, nursing and
rehabilitative care, dietary and nutrition services, activities, social participation, sanitation,
infection control, and the physical environment.  Written plans of care are reviewed to
determine their adequacy and an audit of residents assessments are conducted to
determine the accuracy of such assessments.  There is also a review of facility compliance
of residents rights.
In addition to the regular survey process there are special and extended surveys. 
Special surveys may be conducted within two months of any change in ownership,
8
Survey and Certification: Deficiency Trends OEI-02-98-00331 administration, management, or director of nursing to determine if the change is having an
effect on the quality of care in the facility.  Extended surveys are performed immediately
or within two weeks after the standard survey completion on those facilities found to have
provided substandard quality of care.  The survey team reviews the policies and
procedures that produced the substandard care, expands the size of the sample of
residents assessments, reviews staffing, in-service training, and if necessary, contracts
with consultants.  
Complaint Procedures
Each State is required to maintain written procedures and adequate staff to investigate
complaints of violations at nursing homes.  States must review all allegations of resident
neglect and abuse, and misappropriation of resident property.  All allegations, regardless
of source, must be reviewed in a timely manner.  If an allegation is found to have
occurred, the State must notify in writing, the individuals implicated and the administrator
of the nursing home where the incident transpired.  In addition, each State is required to
notify the nurse aid registry and licensure boards when an abuse or neglect claim has been
substantiated. 
Online Survey Certification and Reporting System (OSCAR)
The HCFAs Online Survey Certification and Reporting System (OSCAR) came online in
October 1991 as a replacement for the Medicare/Medicaid Automated Certification
System (MMACS) and the Rapid Data Retrieval System (RADARS).  The HCFA uses
OSCAR in its survey of Medicare and Medicaid providers to monitor State agency and
provider performance.  OSCAR contains data for the current and 3 previous surveys. 
Some of the data is overwritten as new information is entered (e.g. number of beds,
address, and employment information), but deficiency data remains and is tracked
historically.  The HCFA recently began tracking the scope and severity of deficiencies
historically as well.
Part of the OSCAR data is self-reported information by the nursing homes about the
facility and its patients.  The remaining data is information generated by the surveyors
based on deficiencies.  The Federal regulations detailing survey requirements are classified
into 17 major categories in the HCFA State Operations Manual:  
  < resident rights; 
  < admission, transfer and discharge rights; 
  < resident behavior and facility practices; 
  < quality of life;
  < resident assessment;
  < quality of care;
  < nursing services; 
9
Survey and Certification: Deficiency Trends OEI-02-98-00331   < dietary services;
  < physician services;
  < rehabilitation services;
  < dental services;
  < pharmacy services;
  < infection control;
  < physical environment; 
  < administration;
  < laboratory; and
  < other.
The specific survey requirements within these categories were consolidated from 325
individual items to 185 items effective on July 1, 1995.  When a nursing home fails to meet
a specific requirement which could result in a negative impact on the health and safety of
residents, a deficiency is given to the facility by a State surveyor team.  A deficiency is
rated based on scope and severity for the purposes of enforcement.  
When a facility has one or more deficiencies related to resident behavior and facility
practices, quality of life, or quality of care that constitute either immediate jeopardy to
resident health and safety; a pattern of or widespread actual harm that is not immediate
jeopardy; or a widespread potential for more than minimal harm, but less than immediate
jeopardy with no actual harm it is considered substandard quality of care.  Resident
behavior and facility practices includes the areas of restraints, abuse and staff treatment of
residents; quality if life includes the residents ability to make decisions about his or her
daily activities and the nursing homes accommodation of those needs; and quality of care
includes the technical ability of the nursing home to prevent and treat the medical
conditions of the residents.  For a complete listing of the deficiencies in each substandard
quality of care category see Appendix B.
Prior Studies 
A recent study, The Regulation and Enforcement of Federal Nursing Home Standards
by Charlene Harrington published in March of 1998, details the problems with nursing
home certification that precipitated the action by Congress in passing the Nursing Home
Reform Act.  She challenges the declining State deficiency averages by raising the notion
that the enforcement process may be weakening rather than nursing facilities improving
quality of care.
The National State Auditors Association Joint Performance Audit on Long-Term Care,
completed in May of 1998 by the Louisiana Office of the Legislative Auditor, compiled
information from ten States regarding survey and certification concerns.  Issues discussed
include licensing, inspection, sanctions, complaints, and reimbursement.  The audit
findings conclude that States should vary the timing of inspections, evaluate how
10
Survey and Certification: Deficiency Trends OEI-02-98-00331 aggressively they are imposing State sanctions on facilities with deficiencies, and avoid
delaying the investigation of complaints.
The Secretary released a report to Congress in July of 1998 indicating that significant
improvements were made since 1995 in the quality of care delivered by nursing homes. 
These improvements included more appropriate use of physical restraints, anti-psychotic
drugs, anti-depressants, urinary catheters, and hearing aids.  The report also found a need
for further improvements by States, nursing homes, and others.  Additional steps will be
taken to address the problems identified in the report and include tougher enforcement of
Medicare and/or Medicaid rules.  Efforts will be aimed at preventing instances of bed
sores, dehydration, and nutrition problems.  The following are new approaches aimed at
improving quality of care: facilities that have repeat offenses will face sanctions without a
grace period; inspections will be conducted more frequently for repeat offenders without
decreasing inspections at other facilities; inspections will be staggered; a set amount of
inspections will be conducted on weekends; and efforts will be focused on facilities within
chains that have a record of non-compliance.  
In conjunction with the Secretarys report to Congress, the President announced a new
nursing home care initiative to provide enhanced protections and to target needed
improvement in nursing home care.  Proposed actions include checking criminal
backgrounds of nursing home workers, establishing a national registry of employees
convicted of abusing patients, targeting nursing home chains with poor records, cutting off
inspection funds to States with poor records of citing substandard quality of care,
publishing annual nursing home surveys on the Internet, increasing Federal oversight of
State inspections, providing additional training to State officials, changing the survey
schedule to make them more unpredictable,  increasing the number of night and weekend
surveys, and re-authorizing the Ombudsman program in the Older Americans Act.
One week after the Presidents initiative, the Government Accounting Office (GAO)
published a report examining the quality of care in 1,370 California nursing homes that
were inspected from 1995 to 1998.  They found 30 percent of the homes had violations
that caused death or life-threatening harm to residents, or had understated the frequency
of poor care by falsifying medical records.  As a result of this report, the US Senate
Special Committee on Aging, chaired by Senator Charles Grassley, held hearings in July
1998 to discuss the findings on the quality of care in nursing homes.
The HCFA has a number of studies in progress evaluating various aspects of survey and
certification.  Some studies include staffing ratios, quality of care, and resident assessment. 
11
Survey and Certification: Deficiency Trends OEI-02-98-00331 METHODOLOGY
This inspection is based on information gathered from three different sources: OSCAR
data, interviews with State survey and certification directors and State survey and
certification surveyors.  We looked for consistencies between the data and the
observations of the insiders we interviewed.  We selected a purposive sample of ten
States: New York, California, Texas, Ohio, Illinois, Pennsylvania, Massachusetts, Florida,
New Jersey, and Tennessee.  These States have comprehensive survey and certification
programs and represent 55.8 percent of the nations total skilled nursing beds.  In addition,
they represent 56 percent ($23 billion) of Medicaid institutional long-term care
expenditures in 1996.  The purposive sample represents States of various sizes in different
parts of the country.
OSCAR Data
The Online Survey Certification and Reporting System (OSCAR) is the system HCFA
uses in its survey of Medicare and Medicaid providers to monitor State agency and
provider performance.  OSCAR contains data for the current and three previous standard
surveys.  The second part of OSCAR is information generated by the surveyors based on
deficiencies.  The Federal regulations detailing survey requirements are classified into 17
major categories.  We analyzed three of these categories which could determine poor
quality of care depending on their scope and severity.  Resident behavior and facility
practices includes the areas of restraints, abuse and staff treatment of residents; quality of
life includes the residents ability to make decisions about his or her daily activities and the
nursing homes accommodation of those needs; and quality of care includes the technical
ability of the nursing home to prevent and treat the medical conditions of the residents. 
We looked at those substandard quality of care deficiencies which increased over the last
four standard surveys, those that decreased and those that remained high, and those
deficiencies that repeated over the last four surveys. 
Additionally, we looked at the top 10 of all deficiencies to determine which deficiencies
are cited most frequently.  We also looked at OSCAR complaint data specifically at
complaints of abuse.  We compared complaints of abuse filed from January 1997 to July
1998 to abuse deficiencies in the most current survey.  The direct relationship between
abuse codes in the deficiency and complaint tables allowed us to look closely at the scope
of abuse and examine enforcement patterns and outcomes.  Since information in the
OSCAR database is constantly being updated, we downloaded OSCAR data on August 4,
1998.  In all cases we compared our 10 sample States to aggregate national data both for
deficiencies and complaints.  
12
Survey and Certification: Deficiency Trends OEI-02-98-00331 Interviews
We also conducted a total of thirty structured interviews; three interviews in each of the
ten sample States, one with the State survey and certification director or a designee, and
two with State surveyors within each State.  The two State surveyors were selected
randomly from a list of at least ten surveyors submitted by the State director.  During
these interviews, we obtained information about the State survey and certification program
structure, the processes utilized to monitor quality of care, how deficiencies are addressed,
and the respondents satisfaction with the process.
We selected both directors and surveyors for their different perspectives on the survey and
certification process.  We compared the information provided by the directors to
information provided by surveyors.  In our analysis we paid special attention to consensus
within and among the groups. 
This inspection was conducted in accordance with the Quality Standards for
Inspections issued by the Presidents Council on Integrity and Efficiency. 
13
Survey and Certification: Deficiency Trends OEI-02-98-00331 F I N D I N G S
Overall  deficiencies are decreasing,  but quality of care 
deficiencies are increasing and other serious deficiencies
persist at high levels
General trends 
Potential deficiencies are classified into 17 major categories containing 185 subcategories
of specific deficiencies.  If a nursing home has deficiencies in three specific categories, it 
is considered to have substandard quality of care for enforcement purposes depending on
the scope and severity.  These three categories are: quality of care, resident behavior
and facility practices, and quality of life. 
Resident behavior and facility practices and quality of life, two of the three
substandard quality of care categories, are lower in the current standard survey than they
were in the prior three.  See Appendix A for a complete listing of the deficiencies in these
categories.  In addition, some quality of care deficiencies have also decreased over the
past four surveys.  In all three substandard quality of care categories, nine deficiencies
have decreased by more than 50 percent between the current survey and three surveys
prior.  See Table I below.
Table I
Deficiencies that have Decreased by More than 50 percent
Deficiencies Percent Decrease
Facility promotes/enhances  -87%
quality of life
Facility must employ a qualified social -79%
worker
Private closet space -74%
Facility must listen and respond to -72%
groups
Adequate and comfortable light -61%
Clean bed and bath linens -55%
14
Survey and Certification: Deficiency Trends OEI-02-98-00331 Gradual dose reduction of  -55%
antipsychotic drugs
No naso-gastric tube unless unavoidable -53%
Right to be free from chemical restraints -52%
Source: OSCAR Data
On the national level, six deficiencies decreased by 50 percent or more.  Five deficiencies
mirror those of the sample States in addition to failure to provide activities of daily living
to dependent residents which has also declined over 50 percent.  About 40 percent (20 out
of 49) of all deficiencies in the three substandard quality of care categories have declined
every survey for the past four surveys.  These declines range from a 10 percent decline to
a 79 percent decline.  Nationally, 30 percent (15 out of 49) of all deficiencies declined
every survey with decreases ranging from 17 percent to 75 percent.  
We compared the 49 deficiencies in the 3 substandard quality of care categories to the
other 136 deficiencies. The 49 substandard quality of care deficiencies have decreased by
only 14 percent over the last four standard surveys compared to a 32 percent decrease for
all other deficiencies that do not fall in the substandard quality of care category.  See
Figure I below.  
Figure I
Sample State Deficiency Trends in Four Consecutive Surveys
Source: OSCAR Data
15
Survey and Certification: Deficiency Trends OEI-02-98-00331 The slower decrease in substandard quality of care deficiencies has in effect increased
their proportion among all OSCAR deficiencies.  As mentioned before, certain
substandard quality of care deficiencies in the quality of care category  have actually
increased such as the failure to supply range of motion treatment and services, failure to
provide supervision or devices to prevent accidents, and failure to provide proper
treatment or heal pressure sores.  When we look at national substandard quality of care
deficiencies, they mirror the trend of those in sample States.
Sample State outliers to the above trend include New Jersey, Florida, and Illinois.  New
Jersey differs from the trend because substandard quality of care deficiencies decreased at
a faster rate (46 percent) than all others (26 percent).  Substandard quality of care
deficiencies in Florida and Illinois have actually increased (12 percent in Florida and 11 
percent in Illinois), while all other deficiencies decreased (6 percent in Florida and 33
percent in Illinois).
Quality of care deficiencies
Thirteen of the 25 quality of care deficiencies in sample States are higher on the current
survey than they were three surveys prior.  These 13 deficiencies were cited 6,413 times
on the current survey compared to 5,246 times three surveys prior, an increase of almost
25 percent.  See Table II below for a listing of the 13 deficiencies that have increased over
the past 3 surveys.  See Appendix A for a complete listing of all quality of care
deficiencies and their survey trends.
Table II
Increasing Deficiencies Over Past Three Surveys
Deficiencies Percent Increase
Adequate supervision and/or devices to prevent +79%
accidents
Appropriate range of motion treatment +48%
Resident not catheterized unless unavoidable +42%
Resident receives treatment to maintain vision +35%
and hearing
ADL care provided for dependent residents +33%
No reduction in range of motion unless +29%
unavoidable
16
Survey and Certification: Deficiency Trends OEI-02-98-00331 Proper treatment to prevent or treat pressure +21%
sores
Resident given appropriate treatment to improve +8%
abilities
Proper treatment and care for special needs +7%
No development of mental problems unless +5%
unavoidable
Appropriate treatment for incontinence +5%
Provides necessary care for highest practicable +4%
well-being 
Proper care for residents with naso-gastric tubes +1%
Source: OSCAR Data
Additionally, 3 of the 13 quality of care deficiencies that have increased, have increased
in every survey for the past four surveys.  These three include nursing homes catheterizing
residents without demonstrating clinical need, the nursing homes failure to provide range
of motion treatment, and the lack of supervision and/or devices to prevent accidents.  See
Figure II below.  
Figure II
Sample State Deficiencies Increasing Every Survey
17
Survey and Certification: Deficiency Trends OEI-02-98-00331 When looking at the  quality of care deficiencies nationwide, 10 deficiencies are higher
on the current survey than they were three surveys prior.  These ten deficiencies were
cited 10,497 times on the current survey compared to 7,726 times three surveys prior, an
increase of 36 percent.  Four of these 10 deficiencies have increased in every survey for
the past four surveys.  These include the nursing homes failure to provide necessary care
for high well-being, the failure to provide activities of daily living care for dependent
residents, the lack of supervision and/or devices to prevent accidents, and the failure to
provide range of motion treatment.  See Figure III below.
Figure III
National Deficiencies Increasing Every Survey
 
Source: OSCAR Data
High deficiencies
Although some deficiencies have declined over the years, the number of deficiencies still 
cited is a cause for concern.  Deficiencies often lead to further medical problems or
indicate other issues.  For example, pressure sores are bruises or open sores on the skin
which could be an indication that other kinds of problems are occurring with residents in
the nursing home such as urinary incontinence, malnutrition or dehydration.  If a resident
has a cognitive loss or dementia,  physical restraints, or psychotropic drugs are being used, 
the resident is also vulnerable to resultant pressure sores. 
18
Survey and Certification: Deficiency Trends OEI-02-98-00331 According to OSCAR data, a total of 7,196 nursing homes exist in sample States. Ten
substandard quality of care deficiencies in sample States have been cited more than 699
times on the latest standard survey, affecting more than 10 percent of nursing homes.  Ten
substandard quality of care deficiencies also affect more than 10 percent of nursing homes
nationwide.  Five deficiencies affect at least 13 percent of sample State and national
nursing homes and they include failure to prevent pressure sores, failure to remain free of
accident hazards, failure to maintain or enhance dignity, failure to provide 
housekeeping to maintain sanitary, orderly and comfortable interiors, and failure to
provide the necessary care for the highest practicable well-being.  See Table III below. 
Table III
Top Ten Substandard Quality of Care Deficiencies 
Cited On Latest Standard Survey
Deficiency # of Sample % of # of % of
State Sample National National
Deficiencies State Deficiencies Facilities
Facilities
Proper treatment to prevent or  1,186 16% 2,416 16%
treat pressure sores
Facility is free of accident hazards 1,164 16% 2,381 16%
Facility promotes care that 1,115 16% 2,032 14%
maintains/enhances dignity
Housekeeping and maintenance 1,023 14% 1,916 13%
Provides necessary care for  972 14% 2,247 15%
highest practicable well-being
Right to be free from physical 958 13% 1,942 13%
restraints
Should have policies that accommodate 787 11% 1,348 9%
needs
Drug regimen free from unnecessary 768 11% 1,575 11%
drugs
Appropriate treatment for incontinence 750 10% 1,560 10%
Activities of daily living care 699 10% 1,598 11%
provided for dependent residents
Source: OSCAR data
19
Survey and Certification: Deficiency Trends OEI-02-98-00331 As opposed to the deficiencies cited the most, some deficiencies remain low.  Eighteen
substandard quality of care deficiencies in sample States have been cited less than 100
times on the latest standard survey, affecting less than one percent of nursing homes. 
Examples of some of these deficiencies include feeding residents with naso-gastric tubes
without medical need, hiring non-qualified social workers, facility prevents residents
participation in social, religious, or community activities, and the nursing home fails to
promote maintenance or enhancement of each residents quality of life. 
Nursing homes with chronic quality of care problems exist
While State directors and surveyors express reservations about OSCAR data, interviews
with them support the OSCAR data about repeat offenders.  The OSCAR data shows 463
nursing homes have been cited with the same deficiencies over the past four contiguous
surveys, representing 6 percent of all homes in the sample States.  The number of nursing 
homes with repeat quality of care deficiencies ranges from 2 in New Jersey to 270 in
California.  Table IV shows the number of nursing homes in sample States with repeat
quality of care deficiencies.  
Table IV
Number of Nursing Homes in Sample States with Repeat Substandard
Quality of Care Deficiencies over Four Surveys
State Number of Nursing Percent of Nursing Number of Repeat
Homes with  Homes with Repeat Deficiencies
Repeat Deficiencies Deficiencies
CA 270 21% 369
FL 28 4% 33
IL 54 8% 62
MA 8 2% 8
NJ 2 1% 2
NY 4 1% 4
OH 28 3% 33
PA 10 1% 11
TN 3 1% 3
TX 56 5% 70
Source: OSCAR Data
20
Survey and Certification: Deficiency Trends OEI-02-98-00331 Table V below identifies the number of nursing homes affected by the top 10 repeat
substandard quality of care deficiencies in the 10 sample States.  Failure of the nursing
home to promote care that maintains or promotes dignity ranks first on the list in both the
sample States and the national numbers. 
Table V
Top 10 Substandard Quality of Care Repeat Deficiencies
Deficiency Facilities in Facilities
Sample States  Nationwide
Facility promotes care that  142 174
maintains or enhances dignity  
Facility must provide necessary 91 151
housekeeping and maintenance services 
Facility should have policies that 68 80
accommodate needs and preferences 
Facility is free of accident hazards  64 99
Drug regimen free of unnecessary drugs  33 58
Proper treatment to prevent or treat  27 74
pressure sores 
Right to be free from physical restraints  24 44
Adequate supervision and/or devices to 22 27
prevent accidents 
Facility provides medically related social 19 29
services 
Facility must provide a safe, clean, homelike 15 32
environment 
  Source: OSCAR Data
State directors and surveyors report that nursing homes with chronic quality of care
problems exist in their individual States.  Nursing homes with serious deficiencies or
constant non-compliance issues are considered to have chronic quality of care problems. 
They say that the percentage of nursing homes with these problems is between 1 and 20
percent of all nursing homes in their respective States.  Half of the State directors mention
pressure sores and nutrition issues as frequent chronic quality of care problems in their
nursing homes.  Consistent with these observations, OSCAR data show the deficiency that
21
Survey and Certification: Deficiency Trends OEI-02-98-00331 occurs the most frequently, both in our sample States and nationwide, is the failure to give
proper treatment to prevent or treat pressure sores.  See Table III on page 18.
Surveyors concur with directors, but most also mention that nursing home staffing
shortages and inferior staff proficiency levels precipitate chronic quality of care in nursing
homes.  We looked at staffing ratios in the facility reported section of OSCAR data and
found between six to nine residents for each certified nurse assistant (CNA) and between
36 and 81 residents for each registered nurse (RN) considering three shifts per day.  This
does not account for weekends and days off and is only an average.  Some homes may
have a much higher ratio than others and there is no way of telling if some units within a
nursing home are better staffed than others.  Abuse of restraints, failure to treat
incontinent patients, and improper medication distribution are also mentioned by State
directors and surveyors as deficiencies that lead to substandard quality of care.
State directors and surveyors express reservations about
relying exclusively on OSCAR data to identify and
understand problems in nursing homes 
Snapshot in time
OSCAR data may not catch all the problems that exist in a nursing home due to the
current survey process.  Surveyors visit most facilities only once a year and cannot be
cognizant of problems that occur throughout the year.  Because many surveys do not take
place on weekends on in the evenings, surveyors are limited in their assessment of the
nursing home.  In order to gain the most comprehensive understanding at a nursing home,
OSCAR data should be used in combination with the surveyors visit and other State
specific information. 
More than half of respondents believe that OSCAR data are not a true indicator of nursing
home quality of care.  The quality of care at the nursing home may have drastically
changed for the better or worse.  A common theme among many surveyors and directors
is that OSCAR data only portray the situation of the nursing home at the time surveyors
are physically conducting the survey.  One director remarked, OSCAR is simply a profile
of what is found on the survey.  Surveys depend on the characteristics of unique survey
teams.  Some very bad nursing homes may have a survey that portrays them positively and
some very good nursing facilities may have a survey that portrays them negatively. 
Most surveyors and more than half of directors are satisfied with OSCAR data but note
problems and propose changes.  Surveyors suggest using OSCAR data in conjunction with
other tools to obtain an accurate view of quality of care.  OSCAR is only one part of the
quality of care story, one surveyor said.  A director notes that OSCAR is a useful
22
Survey and Certification: Deficiency Trends OEI-02-98-00331 instrument to help focus a survey team during the pre-survey, but doesnt indicate quality
of care when analyzed alone.  Respondents are concerned that OSCAR data are not user
friendly, accurate, streamlined, accessible, or timely.  Another director said, OSCAR
generated reports are cumbersome and time consuming.  The consensus of the
respondents is that OSCAR is difficult to use.
Unclear definitions
Some deficiency definitions are clear and easy to interpret such as  the facility may not
employ persons who have been found guilty of abuse.  The facility is responsible to
provide information about background checks of their staff.  Other easy to interpret
deficiencies include; a facility with more than 120 beds must employ a qualified social
worker on a full time basis, or a facility must provide private closet space in each
residents room.  
However, other deficiencies hard to define or difficult to detect may be interpreted
differently by various teams of surveyors.  People might feel differently about what
constitutes dignity or whether the nursing home is providing appropriate accident
prevention measures.  
The majority of the State survey and certification directors and surveyors we interviewed
believe that certain deficiencies have unclear definitions.  They note some specific
deficiencies that are open to individual interpretation and discretion.  Of the 17 categories,
those that are considered most problematic are resident rights, resident behavior and
facility practices, quality of life, quality of care, and nursing services.  Specific
deficiencies in these categories include physical and chemical restraints, activities of daily
living, and accidents.  Unclear definitions can cause significant problems when surveyors
are writing their survey reports.  One surveyor notes, some problems just dont fit nicely
into the deficiency categories.  Another surveyor states that the use of psychoactive
drugs is an awkward deficiency because the use of these drugs may be appropriate but the
nursing home may have a poor way of documenting the need.
23
Survey and Certification: Deficiency Trends OEI-02-98-00331 R E C O M M E N D A T I O N
The resident-centered long-term care requirements of the nursing home survey are essential
tp guarantee the quality of care in nursing homes.  Clearly some major problems need to be
addressed.  Our findings support and elaborate on the Health Care Financing
Administrations (HCFA) initiative to strengthen the enforcement efforts by: 
  < making them more timely and effective,
  < changing the survey schedule to make surveys more unpredictable, 
  < increasing the number of night and weekend surveys,
  < increasing the number of surveys at nursing homes with chronic quality of care
problems, and 
  < focusing on specific problems such as pressure sores, dehydration, and malnutrition.
 
These initiatives, if carried out completely, appear to be responsive to most of the problems
in this report as well as our companion report Nursing Home Survey and Certification:
Overall Capacity.
Many of the most frequently cited deficiencies are directly related to reported shortage of
direct care staff.  The failure to provide proper treatment to prevent or treat pressure sores
illustrates the lack of direct care staff to assure that residents are properly hydrated,
nourished and turned frequently.  In light of our findings in this report, additional action is
needed.  We recommend that HCFA: 
  < develop staffing standards for registered nurses and certified nurse assistants in
nursing homes to assure sufficient staff on all shifts to enable residents to have
proper care.  Staffing standards should account for the intensity of care needed,
qualifications of the staff, and the specific characteristics of both the nursing home
and the residents.
AGENCY COMMENTS
We received comments on the draft report from HCFA and the Assistant Secretary for
Planning and Evaluation (ASPE).  The HCFA concurs with our recommendations.  The
ASL informally commented on the reports, and we made the appropriate changes.
The ASPE expressed some concern about the ability of OSCAR data to assess quality of
care in nursing homes.  We recognize the limitations of OSCAR but used it as only one
indicator of quality. We are happy to re-emphasize here what we say in our report that
24
Survey and Certification: Deficiency Trends OEI-02-98-00331 OSCAR data should not be looked at independently. In this report we used it in
combination with the views of nursing home surveyors and State Directors. 
25
Survey and Certification: Deficiency Trends OEI-02-98-00331 APPENDIX A
Substandard Quality of Care Deficiencies
Table VI
Resident Behavior and Facility Practices Deficiencies in Sample States
Deficiency 3 Surveys 2 Surveys 1 Survey Current Percent
Prior Prior Prior Survey Change  
Right to be free from 1145 1245 1109 958 -16%
physical restraints
Right to be free from 102 83 68 49 -52%
chemical restraints
Right to be free from abuse 205 144 117 112 -45%
Must have policies that 198 172 122 162 -18%
prohibit abuse and neglect
May not employ persons 409 382 300 341 -17%
guilty of abuse
Total 2059 2026 1716 1622 -21%
Source: OSCAR data
26
Survey and Certification: Deficiency Trends OEI-02-98-00331 Table VII
Quality of Life Deficiencies in Sample States
Deficiency 3 Surveys 2 Surveys 1 Survey Current Percent
Prior Prior Prior Survey Change
Facility promotes/enhances  117 38 14 15 -87%
quality of life
Facility promotes care that 1470 1367 1164 1115 -24%
maintains/enhances dignity
Resident has the right to 188 166 148 138 -27%
make choices about aspects
of life in the facility
Right to organize and 60 59 40 35 -42%
participate in groups
Facility must listen and 123 33 27 34 -72%
respond to groups
Right to participate  15 16 11 15 00%
in activities
Should have policies that 1357 1147 835 787 -42%
accommodate needs
Receive notice of room or 51 28 23 31 -39%
roommate change
Facility must provide an 826 810 659 641 -22%
activity program
Facilities activity director 66 46 34 53 -20%
must be fully qualified
Facility provides medically 766 758 712 647 -16%
related social services  
Facility must employ a 56 27 26 12 -79%
qualified social worker
Facility must provide a safe, 984 774 548 510 -48%
clean, homelike environment
27
Survey and Certification: Deficiency Trends OEI-02-98-00331 Housekeeping maintains 1242 1076 1057 1023 -18%
sanitary and comfortable
interior
Clean bed and bath linens 214 150 121 96 -55%
Private closet space 57 33 14 15 -74%
Adequate and comfortable 90 67  44 35 -61%
light
Safe and comfortable 119 76 61 75 -37%
temperature levels
Maintenance of comfortable 220 204 178 157 -29%
sound levels
Total 8021 6875 5716 5434 -32%
Source: OSCAR data
28
Survey and Certification: Deficiency Trends OEI-02-98-00331 Table VIII
Quality of Care Deficiencies in Sample States
Deficiency 3 Surveys 2 Surveys 1 Survey Current Percent
Prior Prior Prior Survey Change
Provides necessary care for 939 887 923 972 +04%
highest practicable well-being 
ADLs dont decline unless 346 268 212 201 -42%
unavoidable
Resident given appropriate 314 313 320 339 +08%
treatment to improve abilities
ADL care provided for 527 654 568 699 +33%
dependent residents
Resident receives treatment to 37 56 58 50 +35%
maintain vision and hearing
Proper treatment to prevent 984 1061 1005 1186 +21%
or treat pressure sores
Resident not catheterized 72 97 98 102 +42%
unless unavoidable
Appropriate treatment for 714 730 663 750 +05%
incontinence
No reduction in range of 51 67 66 66 +29%
motion unless unavoidable
Appropriate range of motion 411 537 548 607 +48%
treatment
Appropriate treatment for 280 261 221 208 -26%
mental or psychosocial
functioning
No development of mental 20 22 13 21 +05%
problems unless unavoidable
No naso-gastric tube unless 19 26 15 9 -53%
unavoidable
29
Survey and Certification: Deficiency Trends OEI-02-98-00331 Proper care for residents with 367 364 308 369 +01%
naso-gastric tubes
Facility is free of accident 1402 1255 1147 1164 -17%
hazards
Adequate supervision and/or 532 699 778 954 +79%
devices to prevent accidents
Resident maintains nutrition 633 612 600 569 -10%
status unless unavoidable
Resident receives therapeutic 325 216 153 179 -45%
diet when required
Facility provides sufficient 261 251 226 230 -12%
fluid intake to maintain health
Proper treatment and care for 278 282 257 298 +07%
special needs
Drug regimen free from 785 784 786 768 -02%
unnecessary drugs
No use of antipsychotic drugs 101 75 69 65 -36%
except when necessary
Gradual dose reduction of 115 90 76 52 -55%
antipsychotic drugs
Facility is free of medication 436 391 345 330 -24%
error rates of 5% or more
Residents are free from 272 216 188 215 -21%
significant medication errors
Total 10221 10214 9643 10403 0.02
Source: OSCAR data
30
Survey and Certification: Deficiency Trends OEI-02-98-00331 APPENDIX B
Definitions of Substandard Quality of Care Deficiencies
Resident Behavior and Facility Practices Category
Deficiency - (Ftag) Definition
F0221 Resident has the right to be free from any physical restraint for
purposes of discipline or convenience.
F0222 Resident has the right to be free from any chemical restraint for
purposes of discipline or convenience.
F0223 Resident has the right to be free from verbal, sexual, physical and
mental abuse, corporal punishment, and involuntary seclusion.
F0224 Facility must have written policies and procedures that prohibit
abuse and neglect.
F0225 Facility may not employ persons who have been found guilty of
abuse
. 
Quality of Life Category
Deficiency - (Ftag) Definition
F0240 Facility must promote/enhances quality of life.
F0241 Facility must promote care that maintains or enhances dignity.
F0242 Resident has the right to choose activities, schedules, interact with
members of community, and make choices about aspects of life in
the facility.
F0243 Resident has the right to organize and participate in resident
groups.
F0244 Facility must listen and respond to resident or family group.
F0245 Resident has the right to participate in social, religious, and
community activities.
31
Survey and Certification: Deficiency Trends OEI-02-98-00331 F0246 Facility should have policies that accommodate residents needs and
preferences.
F0247 Resident to receive notice before room or roommate in the facility
is changed.
F0248 Facility is to provide ongoing program of activities that fit resident.
F0249 Facilities director must be fully qualified.
F0250 Facility must provide medically related social services.
F0251 Facility with more than 120 beds must employ a qualified social
worker on a full time basis.
F0252 Facility must provide a safe, clean, comfortable, and homelike
environment.
F0253 Facility must provide housekeeping and maintenance services
necessary to maintain a sanitary, orderly and comfortable interior.
F0254 Facility must provide clean bed and bath linens that are in good
condition.
F0255 Facility must provide private closet space in each residents room.
F0256 Facility must provide adequate and comfortable lighting levels in all
areas.
F0257 Facility must provide comfortable and safe temperature levels.
F0258 Facility must provide comfortable sound levels.
Quality of Care Category
Deficiency - (Ftag) Definition
F0309 Facility to provide necessary care for the highest practicable
physical, mental, and psychosocial well being.
F0310 Activities of daily living do not decline unless unavoidable.
F0311 Resident is given treatment to improve abilities.
32
Survey and Certification: Deficiency Trends OEI-02-98-00331 F0312 Activities of daily living care is provided for dependent residents.
F0313 Resident receive treatment to maintain hearing and vision.
F0314 Proper treatment to prevent or treat pressure sores.
F0315 Resident is not catheterized unless unavoidable.
F0316 Appropriate treatment for incontinent resident.
F0317 No reduction of range of motion unless unavoidable.
F0318 Resident with limited range of motion receives appropriate
treatment. 
F0319 Appropriate treatment for mental or psychosocial problems.
F0320 No development of mental problems unless unavoidable.
F0321 No naso-gastric tube unless unavoidable.
F0322 Proper care and services for resident with naso-gastric tube.
F0323 Facility is free of accident hazards.
F0324 Resident receives adequate supervision and assistance devices to
prevent accidents.
F0325 Facility must maintain acceptable parameters of nutritional status
unless unavoidable.
F0326 Resident receives therapeutic diet when required.
F0327 Facility must provide sufficient fluid intake to maintain proper
hydration and health.
F0328 Facility must ensure that proper treatment and care is provided.
F0329 Each residents drug regimen must be free from unnecessary drugs.
F0330 No use of antipsychotic drugs except when necessary.
33
Survey and Certification: Deficiency Trends OEI-02-98-00331 F0331 Residents who use antipsychotic drugs receive gradual dose
reductions.
F0332 Facility must ensure that it is free of medication error rates of five
percent or greater.
F0333 Residents are free of any significant medication errors.
34
Survey and Certification: Deficiency Trends OEI-02-98-00331 APPENDIX C
Comments on the Draft Report
In this appendix, we present in full the comments form the Health Care Financing
Administration, and the Assistant Secretary for Planning and Evaluation.
 
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