COUNTRY VILLA MADERA REHABILITATION & NURSING CENT CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
10/07/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
10/07/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
10/07/2010	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
10/07/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
10/07/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
10/07/2010	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
10/07/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/07/2010	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
10/04/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/04/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
10/04/2010	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
10/04/2010	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
10/04/2010	Keep assessments completed in the preceding 15 months in the resident's active record.	Isolated	Minimal harm or potential for actual harm
10/04/2010	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
10/04/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
10/04/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/04/2010	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
09/22/2009	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
09/22/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
09/22/2009	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Isolated	Minimal harm or potential for actual harm
09/22/2009	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
09/22/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
09/22/2009	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
09/22/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
09/22/2009	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
09/22/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
09/17/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
09/17/2009	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
09/17/2009	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
08/13/2008	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
08/13/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
08/13/2008	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
08/13/2008	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
08/13/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
08/13/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
08/13/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
08/13/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
08/13/2008	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
08/13/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
08/13/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
08/13/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
08/13/2008	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
08/13/2008	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
08/13/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
08/13/2008	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
08/13/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
08/13/2008	weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
08/13/2008	properly installed electrical wiring and equipment.	Pattern	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