FIRCREST CONVALESCENT HOSPITAL CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
05/28/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
05/28/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
05/28/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
05/28/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
05/28/2010	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
05/28/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
05/28/2010	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
05/28/2010	did not have a written emergency evacuation plan.	Widespread	Potential for minimal harm
05/28/2010	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
05/28/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
05/28/2010	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
05/28/2010	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
05/28/2010	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
05/28/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
05/20/2010	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
05/20/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
05/20/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
05/20/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
05/20/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
05/20/2010	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
05/20/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
05/20/2010	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Minimal harm or potential for actual harm
05/20/2010	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
05/20/2010	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
05/06/2009	approved construction type or materials.	Widespread	Potential for minimal harm
05/06/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
05/06/2009	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
05/06/2009	a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
05/06/2009	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
05/06/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
05/06/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
05/06/2009	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
05/06/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
04/30/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Hire enough skilled workers to carry out dietary service.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
04/30/2009	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
04/30/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
07/24/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
07/24/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
07/24/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
07/24/2008	properly working sprinkler alarm system.	Isolated	Minimal harm or potential for actual harm
07/24/2008	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
07/24/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
07/24/2008	an approved back-up procedure for a faulty fire alarm system.	Isolated	Minimal harm or potential for actual harm
06/27/2008	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.	Isolated	Minimal harm or potential for actual harm
06/27/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
06/27/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
06/27/2008	Use a registered nurse at least 8 hours a day, 7 days a week.	Pattern	Minimal harm or potential for actual harm
06/27/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
06/27/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
06/27/2008	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
06/27/2008	Keep accurate and appropriate medical records.	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