A & C CONVALESCENT HOSPITAL OF MILLBRAE CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/20/2011	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
01/20/2011	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/20/2011	signs that state that exit doors are to be kept closed.	Pattern	Minimal harm or potential for actual harm
01/20/2011	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
01/20/2011	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
01/20/2011	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/20/2011	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
01/20/2011	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
01/20/2011	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
01/20/2011	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
01/20/2011	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
01/20/2011	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
01/20/2011	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
01/18/2011	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
01/18/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
01/18/2011	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Have enough backup water supply for important areas of the nursing home.	Pattern	Minimal harm or potential for actual harm
01/18/2011	Obtain a license from the State and local government.	Isolated	Minimal harm or potential for actual harm
01/08/2010	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.	Isolated	Minimal harm or potential for actual harm
01/08/2010	Provide written records when a resident is transferred or discharged.	Isolated	Minimal harm or potential for actual harm
01/08/2010	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
01/08/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
01/08/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
01/08/2010	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
01/08/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
01/08/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/08/2010	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
01/08/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/08/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
01/08/2010	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
01/08/2010	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
01/08/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
01/08/2010	Provide enough emergency electricity.	Widespread	Minimal harm or potential for actual harm
01/08/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
02/03/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/03/2009	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
02/03/2009	proper power supply for life support equipment.	Isolated	Minimal harm or potential for actual harm
01/30/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Isolated	Minimal harm or potential for actual harm
01/30/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
01/30/2009	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
01/30/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death