CAPISTRANO BEACH CARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/25/2010	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
01/25/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
01/25/2010	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
01/25/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
01/25/2010	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
01/25/2010	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
01/25/2010	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
01/25/2010	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
01/25/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/25/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
01/25/2010	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
01/25/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/25/2010	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
01/25/2010	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
01/25/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
01/25/2010	post nurse staffing information.	Pattern	Potential for minimal harm
01/25/2010	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
01/25/2010	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
01/25/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Widespread	Minimal harm or potential for actual harm
01/25/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
01/25/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
01/25/2010	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Isolated	Minimal harm or potential for actual harm
01/25/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
01/25/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
01/25/2010	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
01/25/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
01/25/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
01/25/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
01/25/2010	properly maintained smoke detectors.	Widespread	Potential for minimal harm
01/25/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
01/25/2010	portable fire extinguishers.	Widespread	Potential for minimal harm
10/16/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
10/16/2008	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
10/16/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
10/16/2008	exits that are free from obstructions and can be used at all times.	Pattern	Potential for minimal harm
10/16/2008	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
10/10/2008	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
10/10/2008	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
10/10/2008	Assess the resident when the resident enters the nursing home, in a timely manner.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm
10/10/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/10/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/10/2008	post nurse staffing information.	Pattern	Potential for minimal harm
10/10/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/10/2008	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
10/10/2008	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
10/10/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
10/10/2008	Train all employees on what to do in an emergency.	Pattern	Potential for minimal harm
09/11/2007	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
09/11/2007	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
09/11/2007	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
09/11/2007	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
09/11/2007	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
09/11/2007	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
08/30/2007	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
08/30/2007	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
08/30/2007	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
08/30/2007	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
08/30/2007	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
08/30/2007	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
08/30/2007	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
08/30/2007	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
08/30/2007	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
08/30/2007	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
08/30/2007	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
08/30/2007	1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator.	Isolated	Minimal harm or potential for actual harm
08/30/2007	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
08/30/2007	Have a detailed, written plan for disasters and emergencies.	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