ASHBY CARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/27/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/27/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
12/27/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
12/27/2010	rooms that can be unlocked from inside without a key.	Isolated	Minimal harm or potential for actual harm
12/27/2010	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
12/27/2010	did not have a written emergency evacuation plan.	Pattern	Minimal harm or potential for actual harm
12/27/2010	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
12/27/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
12/27/2010	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
12/27/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
12/27/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
12/27/2010	restrictions on the use of flammable curtains.	Widespread	Potential for minimal harm
12/27/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
12/23/2010	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm
12/23/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/23/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/23/2010	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
12/23/2010	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
12/23/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
12/23/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/23/2010	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
12/23/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/23/2010	Have enough outside airflow.	Widespread	Potential for minimal harm
12/23/2010	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
06/29/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
06/29/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
06/29/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
06/29/2010	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
06/29/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
06/29/2010	a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
06/29/2010	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
06/29/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
06/29/2010	back-up procedures in place for a faulty automatic sprinkler system.	Isolated	Minimal harm or potential for actual harm
06/29/2010	an approved back-up procedure for a faulty fire alarm system.	Isolated	Minimal harm or potential for actual harm
06/25/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
06/25/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
06/25/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
06/25/2010	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
06/25/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
06/25/2010	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
07/01/2009	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
07/01/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
07/01/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
07/01/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
07/01/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
07/01/2009	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Give the resident's legal representative the same rights as the resident.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
06/30/2009	Provide written records when a resident is transferred or discharged.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
06/30/2009	Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
06/30/2009	Make sure that each resident's nutritional needs were met.	Pattern	Actual harm
06/30/2009	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
06/30/2009	Use a registered nurse at least 8 hours a day, 7 days a week.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Hire enough skilled workers to carry out dietary service.	Isolated	Minimal harm or potential for actual harm
06/30/2009	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
06/30/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
06/30/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
06/30/2009	Keep all essential equipment working safely.	Widespread	Minimal harm or potential for actual harm
06/30/2009	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
06/30/2009	Set up or keep a group of people to review and ensure quality.	Widespread	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