IMPERIAL MANOR CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/03/2010	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
11/03/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
11/03/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
11/03/2010	restrictions on the use of flammable curtains.	Widespread	Minimal harm or potential for actual harm
11/03/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
11/03/2010	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
10/29/2010	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Isolated	Minimal harm or potential for actual harm
10/29/2010	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
10/29/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/29/2010	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
10/29/2010	Keep all essential equipment working safely.	Widespread	Minimal harm or potential for actual harm
10/29/2010	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
10/29/2010	Quickly tell the resident's doctor the results of x-rays and other tests.	Isolated	Minimal harm or potential for actual harm
11/18/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
11/18/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
11/18/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
11/18/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
11/18/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
11/19/2008	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
11/19/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
11/19/2008	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
11/19/2008	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
11/19/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
11/19/2008	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
11/19/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
11/07/2008	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
11/07/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
11/07/2008	Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed when the resident temporarily leaves the facility.	Isolated	Minimal harm or potential for actual harm
11/07/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
11/07/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
11/07/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Widespread	Minimal harm or potential for actual harm
11/07/2008	Assess the resident when the resident enters the nursing home, in a timely manner.	Isolated	Minimal harm or potential for actual harm
11/07/2008	Do an assessment of the resident every year.	Pattern	Minimal harm or potential for actual harm
11/07/2008	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Minimal harm or potential for actual harm
11/07/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/07/2008	Keep assessments completed in the preceding 15 months in the resident's active record.	Widespread	Minimal harm or potential for actual harm
11/07/2008	Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress.	Widespread	Minimal harm or potential for actual harm
11/07/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
11/07/2008	post nurse staffing information.	Widespread	Potential for minimal harm
11/07/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
11/07/2008	Get rid of garbage properly.	Widespread	Potential for minimal harm
11/07/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
11/07/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
11/07/2008	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
11/07/2008	Have a detailed, written plan for disasters and emergencies.	Widespread	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