KAISER PERMANENTE POST ACUTE CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
09/29/2010	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
09/29/2010	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
09/29/2010	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm
09/29/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
09/29/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
09/29/2010	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
09/29/2010	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
09/29/2010	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
09/29/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
09/29/2010	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
09/29/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
09/29/2010	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
09/29/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
09/29/2010	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
09/29/2010	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
09/29/2010	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
09/29/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
09/29/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
09/29/2010	exits that are accessible at all times.	Widespread	Immediate jeopardy to resident health or safety
09/29/2010	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
09/29/2010	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
09/29/2010	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
09/29/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
09/29/2010	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
09/29/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
09/29/2010	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
09/29/2010	restrictions on the use of portable space heaters.	Isolated	Minimal harm or potential for actual harm
09/29/2010	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
09/29/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
09/29/2010	no-smoking signs where oxygen is used.	Isolated	Minimal harm or potential for actual harm
09/29/2010	weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
09/29/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
07/28/2009	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
07/28/2009	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
07/28/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
07/28/2009	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
07/28/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
07/28/2009	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
07/28/2009	restrictions on the use of highly flammable materials.	Widespread	Potential for minimal harm
07/28/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
07/28/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
07/28/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
07/23/2009	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm
07/23/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
07/23/2009	Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
07/23/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/23/2009	Keep all essential equipment working safely.	Pattern	Potential for minimal harm
07/23/2009	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
07/02/2008	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
07/02/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
07/02/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
07/02/2008	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
07/02/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
07/02/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
06/13/2008	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
06/13/2008	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
06/13/2008	Develop a plan with the resident and family for the resident's care after leaving the nursing home.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
06/13/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
06/13/2008	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