EMERALD TERRACE CONV HOSPITAL CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/23/2009	Tell the resident completely about his or her health status.	Pattern	Potential for minimal harm
12/23/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal harm
12/23/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Widespread	Potential for minimal harm
12/23/2009	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Potential for minimal harm
12/23/2009	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Widespread	Potential for minimal harm
12/23/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home.	Pattern	Potential for minimal harm
12/23/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Train all employees on what to do in an emergency.	Pattern	Potential for minimal harm
12/22/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
12/22/2009	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
12/22/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/22/2009	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
12/22/2009	properly located and lighted "Exit" signs.	Widespread	Minimal harm or potential for actual harm
12/22/2009	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
12/22/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
12/22/2009	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
12/22/2009	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
12/22/2009	a separate and independent backup electrical power source.	Widespread	Minimal harm or potential for actual harm
10/10/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
10/10/2008	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
10/10/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
10/10/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
10/10/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
10/10/2008	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
10/10/2008	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Potential for minimal harm
10/10/2008	fire safety features required by current fire safety codes.	Pattern	Potential for minimal harm
09/20/2008	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
09/20/2008	Let each resident choose whether to manage his or her own money or deposit it with the nursing home.	Pattern	Potential for minimal harm
09/20/2008	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
09/20/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
09/20/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
09/20/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
09/20/2008	Provide a tasty and well-balanced diet that meets the nutritional needs of each resident.	Isolated	Minimal harm or potential for actual harm
09/20/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
09/20/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/25/2007	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
07/25/2007	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
07/25/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/25/2007	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
07/25/2007	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
07/25/2007	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
07/17/2007	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
07/17/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
07/17/2007	post nurse staffing information.	Pattern	Potential for minimal harm
07/17/2007	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
07/17/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
07/17/2007	Provide needed housekeeping and maintenance.	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