LA VILLA GRANDE CARE CENTER CO DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/07/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
01/07/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/07/2010	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
01/07/2010	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
12/17/2009	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
12/17/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Widespread	Minimal harm or potential for actual harm
12/17/2009	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
12/17/2009	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
12/17/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/17/2009	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
12/17/2009	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
12/17/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/17/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
12/17/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
12/17/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
12/17/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/17/2009	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
12/17/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
12/17/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
12/17/2009	Have enough backup water supply for important areas of the nursing home.	Widespread	Minimal harm or potential for actual harm
12/17/2009	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
12/17/2009	Train all employees on what to do in an emergency.	Widespread	Minimal harm or potential for actual harm
03/24/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
03/24/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
03/24/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
03/24/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
03/24/2009	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Minimal harm or potential for actual harm
03/02/2009	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
03/02/2009	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	Actual harm
03/02/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
03/02/2009	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Pattern	Minimal harm or potential for actual harm
03/02/2009	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
03/02/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
03/02/2009	Assess the resident when the resident enters the nursing home, in a timely manner.	Isolated	Minimal harm or potential for actual harm
03/02/2009	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
03/02/2009	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
03/02/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
03/02/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
03/02/2009	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Actual harm
03/02/2009	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
03/02/2009	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
03/02/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
03/02/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
03/02/2009	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
03/02/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
03/02/2009	Provide enough emergency electricity.	Pattern	Potential for minimal harm
03/02/2009	Have enough backup water supply for important areas of the nursing home.	Widespread	Minimal harm or potential for actual harm
03/02/2009	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
04/10/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
04/10/2008	properly working alarms on sprinkler valves.	Isolated	Minimal harm or potential for actual harm
04/10/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
04/10/2008	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Minimal harm or potential for actual harm
03/19/2008	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
03/19/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
03/19/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
03/19/2008	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
03/19/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
03/19/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
03/19/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
03/19/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
03/19/2008	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
03/19/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
03/19/2008	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
03/19/2008	Keep accurate and appropriate medical records.	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