COUNTRY VILLA OXNARD MANOR HEALTHCARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
07/13/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
07/13/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
07/13/2010	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
07/13/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Tell the resident completely about his or her health status.	Pattern	Minimal harm or potential for actual harm
06/18/2010	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
06/18/2010	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
06/18/2010	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
06/18/2010	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
06/18/2010	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
06/18/2010	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
06/18/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Give professional services that follow each resident's written care plan.	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.	Pattern	Potential for minimal harm
06/18/2010	post nurse staffing information.	Pattern	Potential for minimal harm
06/18/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Offer other nutritional food to each resident who will not eat the food served.	Pattern	Minimal harm or potential for actual harm
06/18/2010	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	Potential for minimal harm
06/18/2010	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
06/18/2010	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
06/18/2010	Properly mark drugs and other similar products.	Isolated	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	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
06/18/2010	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.	Pattern	Potential for minimal harm
06/18/2010	Get services outside the nursing home that meet professional standards.	Pattern	Minimal harm or potential for actual harm
05/27/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
05/27/2009	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
05/27/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
05/27/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
05/27/2009	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
05/27/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
05/27/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
05/27/2009	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
05/27/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
05/22/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm
05/22/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
05/22/2009	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
05/22/2009	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
05/22/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
05/22/2009	post nurse staffing information.	Pattern	Potential for minimal harm
05/22/2009	Hire enough skilled workers to carry out dietary service.	Isolated	Minimal harm or potential for actual harm
05/22/2009	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
05/22/2009	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
05/22/2009	Give or get dental care for each resident.	Isolated	Minimal harm or potential for actual harm
05/22/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
05/22/2009	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
05/22/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
05/08/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
05/08/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
05/08/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
05/08/2008	properly maintained smoke detectors.	Widespread	Potential for minimal harm
05/08/2008	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
05/08/2008	properly sized and located linen or trash receptacles.	Pattern	Minimal harm or potential for actual harm
05/08/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
04/17/2008	Send and promptly deliver unopened mail to residents.	Pattern	Potential for minimal harm
04/17/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
04/17/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
04/17/2008	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
04/17/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/17/2008	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
04/17/2008	Get rid of garbage properly.	Pattern	Potential for minimal harm
04/17/2008	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
04/17/2008	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
04/17/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
04/17/2008	Provide rooms that are big enough for each resident.	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