BISHOP CARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/03/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
06/03/2010	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
06/03/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
06/03/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
06/03/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
06/03/2010	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
05/14/2010	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
05/14/2010	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
05/14/2010	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
05/14/2010	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
05/14/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
05/14/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
06/05/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
06/05/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
06/05/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
06/05/2009	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
06/05/2009	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
06/05/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
06/05/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
06/05/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
06/05/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
04/24/2009	Have licensed, certified, or registered staff to give needed services.	Pattern	Minimal harm or potential for actual harm
04/24/2009	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Pattern	Minimal harm or potential for actual harm
04/24/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
04/24/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
04/24/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
04/24/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
04/24/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
04/24/2009	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
04/24/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
04/24/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
04/24/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
04/24/2009	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
04/24/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
04/24/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
04/24/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
04/24/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
02/29/2008	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
02/29/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
02/29/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/29/2008	Keep sound levels comfortable.	Pattern	Minimal harm or potential for actual harm
02/29/2008	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
02/29/2008	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Minimal harm or potential for actual harm
02/29/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
02/29/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
02/29/2008	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
02/29/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
02/29/2008	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
02/29/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
02/29/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
02/29/2008	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
02/29/2008	Hire a qualified dietician.	Pattern	Minimal harm or potential for actual harm
02/29/2008	Make sure that residents are well nourished.	Widespread	Minimal harm or potential for actual harm
02/29/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
02/29/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
02/29/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/29/2008	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Potential for minimal harm
02/29/2008	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
02/29/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
02/29/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
02/29/2008	Have licensed, certified, or registered staff to give needed services.	Isolated	Minimal harm or potential for actual harm
02/21/2008	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Potential for minimal harm
02/21/2008	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
02/21/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Potential for minimal harm
02/21/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
02/21/2008	record of quarterly fire drills for each shift under varying conditions.	Pattern	Potential for minimal harm
02/21/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
02/21/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
02/21/2008	portable fire extinguishers.	Pattern	Potential for minimal harm
02/21/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Potential for minimal harm
02/21/2008	proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Minimal harm or potential for actual harm
02/21/2008	fire safety features required by current fire safety codes.	Widespread	Minimal harm or potential for actual harm
02/21/2008	properly installed electrical wiring and equipment.	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