MEDICAL CENTER CONV HOSP CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/22/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
12/22/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
12/22/2010	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Minimal harm or potential for actual harm
12/22/2010	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
12/22/2010	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
12/22/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
12/22/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
12/22/2010	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
12/22/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
12/22/2010	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
12/22/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
12/22/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
12/16/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/16/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/16/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
12/16/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
12/16/2010	Develop/implement required procedures for the administration of immunizations.	Widespread	Potential for minimal harm
12/16/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/16/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
12/16/2010	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
12/16/2010	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
12/16/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/16/2009	proper stairway enclosures and vertical shafts.	Isolated	Minimal harm or potential for actual harm
12/16/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/16/2009	rooms that can be unlocked from inside without a key.	Isolated	Minimal harm or potential for actual harm
12/16/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
12/16/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
12/16/2009	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
12/16/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
12/16/2009	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
12/16/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
12/10/2009	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
12/10/2009	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.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/10/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
12/10/2009	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
12/10/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/10/2009	Get rid of garbage properly.	Widespread	Minimal harm or potential for actual harm
12/10/2009	Put firmly secured handrails on each side of hallways.	Isolated	Minimal harm or potential for actual harm
12/23/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/23/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
12/23/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/23/2008	emergency lighting that can last at least 1 1/2 hours.	Widespread	Potential for minimal harm
12/23/2008	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
12/23/2008	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
12/23/2008	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
12/23/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
12/23/2008	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
12/23/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
12/23/2008	proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm
12/23/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
12/23/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Tell the resident completely about his or her health status.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
12/18/2008	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
12/18/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
12/18/2008	Have a program to keep infection from spreading.	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