HAYWARD HEALTHCARE & WELLNESS CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/01/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/01/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
12/01/2010	restrictions on the use of highly flammable materials.	Isolated	Minimal harm or potential for actual harm
11/19/2010	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
11/19/2010	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
11/19/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
11/19/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
11/19/2010	Listen to the resident or family groups or act on their complaints or suggestions.	Isolated	Minimal harm or potential for actual harm
11/19/2010	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
11/19/2010	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
11/19/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
11/19/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
11/19/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
11/19/2010	Offer other nutritional food to each resident who will not eat the food served.	Isolated	Minimal harm or potential for actual harm
11/19/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
11/19/2010	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
11/19/2010	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
10/22/2009	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
10/22/2009	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
10/22/2009	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
10/22/2009	properly working alarms on sprinkler valves.	Isolated	Minimal harm or potential for actual harm
10/22/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
10/22/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/22/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
09/04/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
09/04/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
09/04/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
09/04/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
09/04/2009	Have a detailed, written plan for disasters and emergencies.	Isolated	Minimal harm or potential for actual harm
09/04/2009	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
08/18/2008	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
08/18/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
08/18/2008	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
08/18/2008	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
06/27/2008	Provide care for each resident in a way that keeps or builds the resident's quality of life.	Isolated	Minimal harm or potential for actual harm
06/27/2008	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
06/27/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
06/27/2008	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
06/27/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Potential for minimal harm
06/27/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	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	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
06/27/2008	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
06/27/2008	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
06/27/2008	Have a detailed, written plan for disasters and emergencies.	Pattern	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