DESERT KNOLLS CONV. HOSPITAL CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/10/2010	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
06/10/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
06/10/2010	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
06/10/2010	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
06/10/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
06/10/2010	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
06/10/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Actual harm
06/10/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Immediate jeopardy to resident health or safety
06/10/2010	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
06/10/2010	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Pattern	Minimal harm or potential for actual harm
06/10/2010	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
06/10/2010	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
06/10/2010	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
06/10/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
06/10/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
06/10/2010	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
06/10/2010	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
06/10/2010	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
06/10/2010	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Widespread	Minimal harm or potential for actual harm
06/10/2010	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
06/10/2010	Choose a doctor to be the medical director.	Isolated	Minimal harm or potential for actual harm
06/10/2010	Keep accurate and appropriate medical records.	Widespread	Minimal harm or potential for actual harm
06/10/2010	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
06/10/2010	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
06/08/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
06/08/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
06/08/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
06/08/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
06/08/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
06/08/2010	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
06/08/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
06/08/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
06/08/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
06/08/2010	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
06/08/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
03/17/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
03/17/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
03/17/2009	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
03/17/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
03/17/2009	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
03/10/2009	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
03/10/2009	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.	Isolated	Minimal harm or potential for actual harm
03/10/2009	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
03/10/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
03/10/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
03/10/2009	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
03/10/2009	Keep assessments completed in the preceding 15 months in the resident's active record.	Isolated	Minimal harm or potential for actual harm
03/10/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
03/10/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
03/10/2009	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
03/10/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
03/10/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
03/10/2009	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
03/10/2009	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
03/10/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
03/10/2009	Put firmly secured handrails on each side of hallways.	Isolated	Minimal harm or potential for actual harm
04/02/2008	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
04/02/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
04/02/2008	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
04/02/2008	Keep safe, clean and homelike surroundings.	Pattern	Potential for minimal harm
04/02/2008	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
04/02/2008	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
04/02/2008	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
04/02/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Immediate jeopardy to resident health or safety
04/02/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
04/02/2008	Develop/implement required procedures for the administration of immunizations.	Widespread	Minimal harm or potential for actual harm
04/02/2008	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
04/02/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
04/02/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
04/02/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
04/02/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
04/02/2008	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	Immediate jeopardy to resident health or safety
04/02/2008	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
04/02/2008	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
03/25/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
03/25/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
03/25/2008	rooms that can be unlocked from inside without a key.	Pattern	Minimal harm or potential for actual harm
03/25/2008	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
03/25/2008	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
03/25/2008	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
03/25/2008	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
03/25/2008	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
03/25/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
03/25/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm

Have you or someone you know become a victim of nursing home abuse or neglect? If so, contact one of our experienced nursing home lawyers today. Help End Nursing Home Abuse

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