GARDEN GROVE CONVALESCENT HOSP CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/08/2011	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
02/08/2011	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/08/2011	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
02/03/2011	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
02/03/2011	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Potential for minimal harm
02/03/2011	Let residents complain without being treated differently or badly.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm
02/03/2011	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
02/03/2011	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
02/03/2011	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
02/03/2011	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
02/03/2011	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
02/03/2011	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
02/03/2011	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
02/03/2011	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Potential for minimal harm
02/03/2011	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
02/03/2011	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
02/03/2011	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
02/03/2011	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
02/03/2011	Put firmly secured handrails on each side of hallways.	Pattern	Potential for minimal harm
02/03/2011	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Potential for minimal harm
02/03/2011	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
02/03/2011	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Pattern	Minimal harm or potential for actual harm
02/03/2011	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
02/03/2011	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
11/12/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
11/12/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
11/12/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
11/12/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
11/12/2009	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
11/12/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
11/04/2009	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
11/04/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
11/04/2009	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
11/04/2009	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
11/04/2009	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
11/04/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
11/04/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
11/04/2009	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Potential for minimal harm
12/18/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
12/18/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/18/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
12/18/2008	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
12/18/2008	portable fire extinguishers.	Widespread	Potential for minimal harm
12/18/2008	proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm
12/18/2008	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
12/18/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
12/11/2008	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
12/11/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
12/11/2008	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
12/11/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/11/2008	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
12/11/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
12/11/2008	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
12/11/2008	Make sure that residents are well nourished.	Pattern	Potential for minimal harm
12/11/2008	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
12/11/2008	Have a program to keep infection from spreading.	Pattern	Potential for minimal harm
12/11/2008	Train all employees on what to do in an emergency.	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