COUNTRY HILLS HEALTH CARE CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/11/2011	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
01/11/2011	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/11/2011	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
01/11/2011	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
01/11/2011	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
01/11/2011	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Potential for minimal harm
01/11/2011	restrictions on the use of flammable curtains.	Isolated	Minimal harm or potential for actual harm
01/11/2011	weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
01/11/2011	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/06/2011	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
01/06/2011	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
01/06/2011	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
01/06/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/06/2011	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
01/06/2011	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
01/06/2011	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
01/06/2011	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
01/06/2011	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
02/18/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
02/18/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
02/18/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/18/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
02/18/2010	protected exits that allow the resident to escape the building.	Isolated	Minimal harm or potential for actual harm
02/18/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
02/18/2010	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
02/18/2010	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
02/18/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
02/18/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
02/18/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/29/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
01/29/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Potential for minimal harm
01/29/2010	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
01/29/2010	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
01/29/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
01/29/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
01/29/2010	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Pattern	Potential for minimal harm
01/15/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/15/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
01/15/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
01/15/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
01/15/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/15/2009	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
01/15/2009	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
01/15/2009	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
01/15/2009	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
01/15/2009	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
01/15/2009	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
01/15/2009	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm
01/15/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
01/15/2009	restrictions on the use of portable space heaters.	Widespread	Minimal harm or potential for actual harm
01/15/2009	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
01/15/2009	restrictions on the use of highly flammable materials.	Isolated	Minimal harm or potential for actual harm
01/15/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
01/15/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/15/2009	an elevator that firefighters can control in the event of a fire.	Widespread	Minimal harm or potential for actual harm
01/15/2009	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
12/12/2008	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
12/12/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
12/12/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
12/12/2008	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
12/12/2008	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
12/12/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/12/2008	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
12/12/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/12/2008	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
12/12/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/12/2008	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
12/12/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
12/12/2008	Have a program to keep infection from spreading.	Pattern	Potential for minimal harm
12/12/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
12/12/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm

Have you or someone you know become a victim of nursing home abuse or neglect? If so, contact one of our experienced nursing home lawyers today. Help End Nursing Home Abuse

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