BROOKSIDE SKILLED NURSING HOSPITAL CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
10/28/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
10/28/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
10/28/2010	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
10/28/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
10/28/2010	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
10/22/2010	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
10/22/2010	Protect each resident from all abuse, physical punishment, and being separated from others.	Pattern	Minimal harm or potential for actual harm
10/22/2010	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
10/22/2010	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
10/22/2010	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
10/22/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
10/22/2010	Give or get dental care for each resident.	Pattern	Minimal harm or potential for actual harm
10/22/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/22/2010	Provide bedrooms that hold no more than 4 residents per room.	Widespread	Potential for minimal harm
10/15/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
10/15/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
10/15/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
10/15/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
10/15/2009	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
10/15/2009	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm
10/15/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
10/15/2009	restrictions on the use of highly flammable materials.	Isolated	Minimal harm or potential for actual harm
10/15/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/15/2009	proper power supply for life support equipment.	Isolated	Minimal harm or potential for actual harm
10/15/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
10/09/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
10/09/2009	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
10/09/2009	Keep sound levels comfortable.	Isolated	Minimal harm or potential for actual harm
10/09/2009	Screen residents when they are first admitted to send them to an area with special care for people with developmental disabilities or mental illness, if needed.	Isolated	Minimal harm or potential for actual harm
10/09/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/09/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/09/2009	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
10/09/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
10/09/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/09/2009	Provide bedrooms that hold no more than 4 residents per room.	Pattern	Minimal harm or potential for actual harm
10/09/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm
11/04/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
11/04/2008	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
11/04/2008	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
11/04/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/23/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Minimal harm or potential for actual harm
10/23/2008	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
10/23/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/23/2008	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
10/23/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
10/23/2008	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
10/23/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/23/2008	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Pattern	Minimal harm or potential for actual harm
10/23/2008	Provide bedrooms that hold no more than 4 residents per room.	Widespread	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