EXCELL HEALTH CARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/12/2011	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
01/12/2011	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/12/2011	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
01/12/2011	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
01/12/2011	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
01/12/2011	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/12/2011	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
01/10/2011	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
01/10/2011	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
01/10/2011	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
01/10/2011	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
01/10/2011	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
01/10/2011	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
01/10/2011	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
01/10/2011	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
01/10/2011	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/10/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/10/2011	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
01/10/2011	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/10/2011	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
01/10/2011	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
11/05/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
11/05/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
11/05/2009	proper backup exit lighting.	Isolated	Minimal harm or potential for actual harm
11/05/2009	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
11/05/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
11/05/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/30/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/09/2008	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
10/09/2008	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
10/09/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
10/09/2008	have an adequate water supply for the sprinkler system.	Pattern	Minimal harm or potential for actual harm
10/09/2008	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
10/09/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
10/09/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/09/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
09/18/2008	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.	Isolated	Minimal harm or potential for actual harm
09/18/2008	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
09/18/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
09/18/2008	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal harm
09/18/2008	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
09/18/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
09/18/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/18/2008	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	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