CYPRESS HEALTHCARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
07/14/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
07/14/2010	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
07/14/2010	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
07/14/2010	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
07/14/2010	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
07/14/2010	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
07/14/2010	restrictions on the use of portable space heaters.	Isolated	Minimal harm or potential for actual harm
07/14/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
07/14/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
07/09/2010	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
07/09/2010	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
07/09/2010	Screen residents when they are first admitted to send them to an area with special care for people with developmental disabilities or mental illness, if needed.	Pattern	Potential for minimal harm
07/09/2010	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal harm
07/09/2010	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
07/09/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
07/09/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
07/09/2010	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.	Pattern	Minimal harm or potential for actual harm
07/09/2010	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
07/09/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
07/09/2010	Offer other nutritional food to each resident who will not eat the food served.	Pattern	Potential for minimal harm
07/09/2010	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
07/09/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
07/09/2010	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
07/09/2010	Keep all essential equipment working safely.	Widespread	Minimal harm or potential for actual harm
07/09/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm
07/09/2010	Give or get lab tests to meet the needs of residents.	Pattern	Minimal harm or potential for actual harm
07/09/2010	Train all employees on what to do in an emergency.	Widespread	Minimal harm or potential for actual harm
07/30/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
07/30/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/30/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
07/30/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
07/30/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
07/30/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
07/15/2009	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.	Pattern	Minimal harm or potential for actual harm
07/15/2009	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
07/15/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
07/15/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
07/15/2009	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
07/15/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
07/15/2009	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.	Pattern	Minimal harm or potential for actual harm
07/15/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Potential for minimal harm
07/15/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
07/15/2009	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
07/15/2009	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
07/15/2009	Hire enough skilled workers to carry out dietary service.	Widespread	Minimal harm or potential for actual harm
07/15/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
07/15/2009	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
07/15/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
07/15/2009	Get rid of garbage properly.	Widespread	Minimal harm or potential for actual harm
07/15/2009	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Widespread	Potential for minimal harm
07/15/2009	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
07/15/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
07/15/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
07/15/2009	Keep all essential equipment working safely.	Widespread	Minimal harm or potential for actual harm
07/15/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
07/15/2009	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
07/15/2009	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
07/15/2009	Train all employees on what to do in an emergency.	Widespread	Minimal harm or potential for actual harm
09/30/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
09/30/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
09/30/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
09/30/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
09/30/2008	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
09/19/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
09/19/2008	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
09/19/2008	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
09/19/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
09/19/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
09/19/2008	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
09/19/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
09/19/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/19/2008	Quickly tell the resident's doctor the results of lab tests.	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