ANTELOPE VALLEY HEALTHCARE CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/12/2010	Let residents give themselves their drugs if they are able.	Pattern	Potential for minimal harm
01/12/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Potential for minimal harm
01/12/2010	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
01/12/2010	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
01/12/2010	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
01/12/2010	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
01/12/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/12/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
01/12/2010	Give each resident enough fluids to keep them healthy and prevent dehydration.	Pattern	Minimal harm or potential for actual harm
01/12/2010	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Pattern	Minimal harm or potential for actual harm
01/12/2010	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
01/12/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
01/12/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
01/12/2010	Make sure that residents are well nourished.	Pattern	Potential for minimal harm
01/12/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
01/12/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
01/12/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
01/12/2010	Give lab tests only when the attending doctor ordered them.	Pattern	Potential for minimal harm
01/11/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/11/2010	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
01/11/2010	properly sized and located linen or trash receptacles.	Pattern	Minimal harm or potential for actual harm
01/11/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
01/11/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/17/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
10/17/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
10/17/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
10/14/2008	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
10/14/2008	Try to resolve each resident's complaints quickly.	Pattern	Potential for minimal harm
10/14/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
10/14/2008	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
10/14/2008	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Make sure that a resident who has been able to eat enough alone or with help is not fed by a feeding tube, if possible.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/14/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Pattern	Potential for minimal harm
10/14/2008	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
10/14/2008	Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
10/14/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/30/2007	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
07/30/2007	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
07/30/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/30/2007	a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
07/30/2007	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
07/30/2007	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
07/30/2007	properly sized and located linen or trash receptacles.	Isolated	Minimal harm or potential for actual harm
07/30/2007	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Tell the resident completely about his or her health status.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Keep each resident free from drugs that restrain them, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Provide activities to meet the needs of each resident.	Pattern	Potential for minimal harm
07/17/2007	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
07/17/2007	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Assess the resident when the resident enters the nursing home, in a timely manner.	Pattern	Potential for minimal harm
07/17/2007	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
07/17/2007	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
07/17/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
07/17/2007	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
07/17/2007	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
07/17/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Give each resident enough fluids to keep them healthy and prevent dehydration.	Pattern	Potential for minimal harm
07/17/2007	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
07/17/2007	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.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
07/17/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Provide bedrooms that don't allow residents to see each other when privacy is needed.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Potential for minimal harm
07/17/2007	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Keep accurate and appropriate medical records.	Pattern	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