EVERGREEN ARVIN HEALTHCARE CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/05/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
11/05/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
11/05/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
11/05/2010	properly maintained smoke detectors.	Widespread	Potential for minimal harm
11/05/2010	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
11/05/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
11/05/2010	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
11/05/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
11/05/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
10/29/2010	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
10/29/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/29/2010	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
10/29/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/29/2010	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
10/29/2010	Hire a qualified dietician.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/29/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
10/29/2010	Have enough backup water supply for important areas of the nursing home.	Widespread	Potential for minimal harm
10/29/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
10/29/2010	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
11/04/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
11/04/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
11/04/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
11/04/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
11/04/2009	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
11/04/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
11/04/2009	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
11/04/2009	an approved back-up procedure for a faulty fire alarm system.	Widespread	Potential for minimal harm
10/30/2009	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
10/30/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
10/30/2009	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
10/30/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
10/30/2009	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
10/30/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/30/2009	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.	Pattern	Minimal harm or potential for actual harm
10/30/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
10/30/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
10/30/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
10/30/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
10/30/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
10/30/2009	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
12/05/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
12/05/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
12/05/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/05/2008	a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
12/05/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
12/05/2008	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
12/05/2008	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
12/05/2008	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
12/05/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
12/05/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
12/05/2008	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
11/24/2008	Give the resident's legal representative the same rights as the resident.	Pattern	Minimal harm or potential for actual harm
11/24/2008	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
11/24/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
11/24/2008	Make sure that private space is available in the nursing home for resident groups or residents' families to meet.	Pattern	Potential for minimal harm
11/24/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
11/24/2008	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
11/24/2008	Keep sound levels comfortable.	Pattern	Minimal harm or potential for actual harm
11/24/2008	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
11/24/2008	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
11/24/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/24/2008	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
11/24/2008	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
11/24/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
11/24/2008	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
11/24/2008	Provide a tasty and well-balanced diet that meets the nutritional needs of each resident.	Pattern	Minimal harm or potential for actual harm
11/24/2008	Hire enough skilled workers to carry out dietary service.	Isolated	Minimal harm or potential for actual harm
11/24/2008	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
11/24/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
11/24/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
11/24/2008	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
11/24/2008	Set up or keep a group of people to review and ensure quality.	Pattern	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