CORONA CARE CONVALESCENT CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/29/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
06/29/2010	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
06/29/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	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	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
06/29/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
06/29/2010	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
06/29/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal harm
06/29/2010	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
06/29/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Let each resident choose a personal doctor.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
06/18/2010	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Hire enough skilled workers to carry out dietary service.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
06/18/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Have enough backup water supply for important areas of the nursing home.	Widespread	Minimal harm or potential for actual harm
06/18/2010	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Have a detailed, written plan for disasters and emergencies.	Isolated	Minimal harm or potential for actual harm
06/23/2009	a two-hour-resistant firewall in common walls.	Pattern	Minimal harm or potential for actual harm
06/23/2009	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
06/23/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
06/23/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
06/23/2009	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
06/23/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
06/23/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
06/23/2009	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
06/23/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
06/23/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
06/23/2009	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
06/23/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
06/15/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
06/15/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
06/15/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
06/15/2009	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
06/15/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
06/15/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
06/15/2009	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
06/15/2009	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
08/21/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
08/21/2008	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
08/21/2008	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
08/21/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
08/21/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
08/21/2008	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
08/21/2008	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
08/21/2008	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
08/21/2008	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
08/21/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
08/11/2008	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
08/11/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
08/11/2008	Keep adequate and comfortable lighting in all areas.	Isolated	Minimal harm or potential for actual harm
08/11/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
08/11/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
08/11/2008	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
08/11/2008	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
08/11/2008	Hire a qualified dietician.	Pattern	Minimal harm or potential for actual harm
08/11/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
08/11/2008	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
08/11/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
08/11/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
08/11/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
08/11/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
08/11/2008	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
08/11/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
08/11/2008	Train all employees on what to do in an emergency.	Isolated	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