COUNTRY VILLA SEAL BEACH HEALTHCARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
04/15/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
04/15/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
04/15/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
04/15/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
04/15/2010	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
04/15/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Potential for minimal harm
04/08/2010	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
04/08/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Potential for minimal harm
04/08/2010	Listen to the resident or family groups or act on their complaints or suggestions.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
04/08/2010	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
04/08/2010	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
04/08/2010	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
04/08/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Potential for minimal harm
04/08/2010	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
04/08/2010	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
04/08/2010	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
04/08/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
04/08/2010	Get rid of garbage properly.	Pattern	Potential for minimal harm
04/08/2010	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
04/08/2010	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
04/08/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
04/08/2010	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
04/08/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm
04/08/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
04/08/2010	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
03/03/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
03/03/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
03/03/2009	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
03/03/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
03/03/2009	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
03/03/2009	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
03/03/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
03/03/2009	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
03/03/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
03/03/2009	no-smoking signs where oxygen is used.	Isolated	Minimal harm or potential for actual harm
03/03/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
02/27/2009	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
02/27/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm
02/27/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
02/27/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
02/27/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
02/27/2009	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
02/27/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/27/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
02/27/2009	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
02/27/2009	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
02/27/2009	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
02/27/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
02/27/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
02/27/2009	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
02/27/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
02/27/2009	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
02/27/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
01/08/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
01/08/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/08/2008	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
01/08/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/08/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Potential for minimal harm
01/08/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/08/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
01/08/2008	a fire alarm system that can be heard throughout the facility.	Widespread	Potential for minimal harm
01/08/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
01/08/2008	portable fire extinguishers.	Widespread	Potential for minimal harm
01/08/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
01/08/2008	restrictions on the use of highly flammable materials.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Pattern	Potential for minimal harm
12/14/2007	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
12/14/2007	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
12/14/2007	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
12/14/2007	Keep temperature levels comfortable and safe.	Pattern	Potential for minimal harm
12/14/2007	Keep sound levels comfortable.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
12/14/2007	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
12/14/2007	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
12/14/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Make sure that each resident gets help to keep vision and hearing.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
12/14/2007	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
12/14/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/14/2007	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
12/14/2007	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
12/14/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
12/14/2007	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
12/14/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
12/14/2007	Have a detailed, written plan for disasters and emergencies.	Isolated	Minimal harm or potential for actual harm
12/14/2007	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