CROWN BAY NURSING AND REHABILITATION CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
10/23/2008	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
10/23/2008	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
10/23/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/23/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
10/23/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
10/23/2008	an approved back-up procedure for a faulty fire alarm system.	Widespread	Potential for minimal harm
10/23/2008	properly maintained smoke detectors.	Widespread	Potential for minimal harm
10/23/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
10/23/2008	did not have a written emergency evacuation plan.	Widespread	Potential for minimal harm
10/23/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/23/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
10/23/2008	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
10/23/2008	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Potential for minimal harm
10/23/2008	portable fire extinguishers.	Widespread	Potential for minimal harm
10/23/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Potential for minimal harm
10/17/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/17/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Potential for minimal harm
10/17/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
10/17/2008	Hire enough skilled workers to carry out dietary service.	Widespread	Minimal harm or potential for actual harm
10/17/2008	Hire a qualified dietician.	Widespread	Minimal harm or potential for actual harm
10/17/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/17/2008	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/17/2008	Keep all essential equipment working safely.	Pattern	Potential for minimal harm
10/17/2008	Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
10/17/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
10/17/2008	Have licensed, certified, or registered staff to give needed services.	Widespread	Minimal harm or potential for actual harm
08/22/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Potential for minimal harm
08/22/2007	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
08/22/2007	exits that are accessible at all times.	Pattern	Potential for minimal harm
08/22/2007	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
08/22/2007	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
08/22/2007	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
08/16/2007	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
08/16/2007	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
08/16/2007	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
08/16/2007	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
08/16/2007	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
08/16/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
08/16/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
08/16/2007	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Isolated	Minimal harm or potential for actual harm
08/16/2007	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
08/16/2007	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
08/16/2007	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
08/16/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
08/16/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
08/16/2007	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
08/16/2007	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
08/16/2007	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
08/16/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
08/16/2007	Have a detailed, written plan for disasters and emergencies.	Isolated	Minimal harm or potential for actual harm
08/16/2007	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
08/16/2007	post nurse staffing information.	Pattern	Potential for minimal harm
07/27/2006	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
07/27/2006	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
07/27/2006	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/27/2006	exits that are free from obstructions and can be used at all times.	Widespread	Potential for minimal harm
07/27/2006	an approved back-up procedure for a faulty fire alarm system.	Pattern	Potential for minimal harm
07/27/2006	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
07/27/2006	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Potential for minimal harm
07/27/2006	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
07/27/2006	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
07/27/2006	weekly inspections and monthly testing of generators.	Pattern	Potential for minimal harm
07/27/2006	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
07/27/2006	back-up procedures in place for a faulty automatic sprinkler system.	Pattern	Potential for minimal harm
07/27/2006	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
06/29/2006	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
06/29/2006	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.	Widespread	Potential for minimal harm
06/29/2006	Give the resident's legal representative the same rights as the resident.	Isolated	Minimal harm or potential for actual harm
06/29/2006	Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States.	Widespread	Minimal harm or potential for actual harm
06/29/2006	Make sure that private space is available in the nursing home for resident groups or residents' families to meet.	Pattern	Minimal harm or potential for actual harm
06/29/2006	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Widespread	Minimal harm or potential for actual harm
06/29/2006	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
06/29/2006	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
06/29/2006	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Actual harm
06/29/2006	Provide activities to meet the needs of each resident.	Widespread	Minimal harm or potential for actual harm
06/29/2006	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
06/29/2006	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
06/29/2006	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
06/29/2006	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
06/29/2006	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
06/29/2006	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Minimal harm or potential for actual harm
06/29/2006	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
06/29/2006	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
06/29/2006	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
06/29/2006	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
06/29/2006	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.	Widespread	Minimal harm or potential for actual harm
06/29/2006	Offer other nutritional food to each resident who will not eat the food served.	Isolated	Minimal harm or potential for actual harm
06/29/2006	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
06/29/2006	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
06/29/2006	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Actual harm
06/29/2006	Protect residents from mistreatment, neglect, and/or theft of personal property.	Pattern	Actual harm
06/29/2006	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Actual harm
06/29/2006	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Actual harm
06/29/2006	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
06/29/2006	Provide needed housekeeping and maintenance.	Widespread	Minimal harm or potential for actual harm
06/29/2006	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
06/29/2006	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
06/29/2006	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
06/29/2006	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
06/29/2006	Train all employees on what to do in an emergency.	Widespread	Potential for minimal harm
06/29/2006	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	Actual harm
06/29/2006	Be administered in a way that leads to the highest possible level of well being for each resident.	Pattern	Actual harm
06/29/2006	Hire a qualified social worker; or in homes with more than 120 beds, hire a qualified full-time social worker.	Pattern	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