EVERGREEN BAKERSFIELD POST ACUTE CARE CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/18/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
02/18/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
02/18/2010	properly maintained smoke detectors.	Widespread	Potential for minimal harm
02/18/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
02/18/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
02/18/2010	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
02/18/2010	restrictions on the use of flammable curtains.	Isolated	Minimal harm or potential for actual harm
02/18/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
02/18/2010	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
02/18/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
02/11/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
02/11/2010	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
02/11/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
12/31/2008	approved construction type or materials.	Pattern	Potential for minimal harm
12/31/2008	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
12/31/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
12/31/2008	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
12/31/2008	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
12/31/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
12/31/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Actual harm
12/18/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/18/2008	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
12/18/2008	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.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Actual harm
12/18/2008	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.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Hire a qualified dietician.	Widespread	Minimal harm or potential for actual harm
12/18/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/18/2008	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
12/18/2008	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
11/19/2007	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Minimal harm or potential for actual harm
11/19/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
11/19/2007	Keep safe, clean and homelike surroundings.	Pattern	Potential for minimal harm
11/19/2007	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
11/19/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/19/2007	Keep assessments completed in the preceding 15 months in the resident's active record.	Isolated	Minimal harm or potential for actual harm
11/19/2007	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
11/19/2007	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
11/19/2007	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
11/19/2007	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
11/15/2007	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
11/15/2007	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
11/15/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
11/15/2007	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
11/15/2007	weekly inspections and monthly testing of generators.	Widespread	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