MARLINDA IMPERIAL CONV HOSP CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/27/2010	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.	Widespread	Potential for minimal harm
01/27/2010	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
01/27/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
01/27/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal harm
01/27/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
01/27/2010	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
01/27/2010	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
01/27/2010	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
01/27/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/27/2010	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
01/27/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
01/27/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
01/27/2010	Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
01/27/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
01/27/2010	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Isolated	Minimal harm or potential for actual harm
01/27/2010	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
01/27/2010	Train all employees on what to do in an emergency.	Pattern	Potential for minimal harm
01/25/2010	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
01/25/2010	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
01/25/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal harm
01/25/2010	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
01/25/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/20/2008	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
10/20/2008	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.	Pattern	Minimal harm or potential for actual harm
10/20/2008	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
10/20/2008	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
10/20/2008	Keep each resident free from drugs that restrain them, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
10/20/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
10/20/2008	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
10/20/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/20/2008	Get doctor orders for the resident's immediate care when admitted.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
10/20/2008	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
10/20/2008	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
10/20/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
10/20/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
10/20/2008	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
10/20/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Immediate jeopardy to resident health or safety
10/20/2008	Make sure that residents are safe from serious medication errors.	Pattern	Immediate jeopardy to resident health or safety
10/20/2008	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
10/20/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
10/20/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/20/2008	Give lab tests only when the attending doctor ordered them.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
10/14/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
10/14/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
10/14/2008	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
10/14/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
10/14/2008	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal harm
10/14/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
10/14/2008	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
10/14/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
07/19/2007	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
07/19/2007	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
07/16/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
07/16/2007	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
07/16/2007	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
07/16/2007	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
07/16/2007	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
07/16/2007	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/16/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
07/16/2007	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
07/16/2007	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
07/16/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
07/16/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/16/2007	Keep accurate and appropriate medical records.	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