MONROVIA CONVALESCENT HOSPITAL CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/12/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
02/12/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
02/12/2010	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
02/12/2010	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.	Pattern	Minimal harm or potential for actual harm
02/12/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
02/12/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/12/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
10/20/2008	Assess the resident when the resident enters the nursing home, in a timely manner.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Potential for minimal 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	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
10/20/2008	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.	Pattern	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	Minimal harm or potential for actual harm
10/20/2008	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
10/20/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Potential for minimal harm
10/20/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/20/2008	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Potential for minimal harm
10/20/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
10/20/2008	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
08/24/2007	Let the resident or the resident's representative look at all records.	Pattern	Minimal harm or potential for actual harm
08/24/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Potential for minimal harm
08/24/2007	Keep sound levels comfortable.	Pattern	Potential for minimal harm
08/24/2007	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.	Pattern	Minimal harm or potential for actual harm
08/24/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
08/24/2007	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
08/24/2007	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
08/23/2007	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
08/23/2007	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
08/23/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
08/23/2007	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
08/23/2007	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
08/23/2007	fire safety features required by current fire safety codes.	Widespread	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