NORWOOD PINES ALZHEIMERS CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
07/13/2010	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
07/13/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
07/13/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
07/13/2010	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
07/13/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
07/13/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/13/2010	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
07/13/2010	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
07/13/2010	an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
07/13/2010	properly working alarms on sprinkler valves.	Pattern	Minimal harm or potential for actual harm
07/13/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
07/02/2010	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
07/02/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
07/02/2010	Provide bedrooms that hold no more than 4 residents per room.	Pattern	Potential for minimal harm
07/02/2010	Provide rooms that are big enough for each resident.	Widespread	Potential for minimal harm
07/02/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
07/02/2010	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
07/02/2010	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
07/02/2010	Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
07/02/2010	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	Actual harm
07/02/2010	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
07/02/2010	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Potential for minimal harm
07/02/2010	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
07/02/2010	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
07/02/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
07/02/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
07/02/2010	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
07/02/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/02/2010	post nurse staffing information.	Pattern	Potential for minimal harm
07/02/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
07/02/2010	Get rid of garbage properly.	Pattern	Minimal harm or potential for actual harm
07/02/2010	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
05/13/2009	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
05/13/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
05/13/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
05/13/2009	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
05/13/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
05/13/2009	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
05/13/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Keep each resident free from drugs that restrain them, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
04/10/2009	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
04/10/2009	Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
04/10/2009	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
04/10/2009	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
04/10/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Keep assessments completed in the preceding 15 months in the resident's active record.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Give each resident enough fluids to keep them healthy and prevent dehydration.	Widespread	Potential for minimal harm
04/10/2009	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
04/10/2009	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
04/10/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Widespread	Minimal harm or potential for actual harm
04/10/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Provide bedrooms that hold no more than 4 residents per room.	Widespread	Potential for minimal harm
04/10/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
04/10/2009	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
04/10/2009	Have a detailed, written plan for disasters and emergencies.	Widespread	Potential for minimal harm
04/10/2009	Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
04/03/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
04/03/2008	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Isolated	Minimal harm or potential for actual harm
04/03/2008	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
04/03/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
03/13/2008	Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States.	Isolated	Minimal harm or potential for actual harm
03/13/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
03/13/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
03/13/2008	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
03/13/2008	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
03/13/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
03/13/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
03/13/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
03/13/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
03/13/2008	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
03/13/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
03/13/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
03/13/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
03/13/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
03/13/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
03/13/2008	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
03/13/2008	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
03/13/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
03/13/2008	Provide bedrooms that hold no more than 4 residents per room.	Pattern	Potential for minimal harm
03/13/2008	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Widespread	Potential for minimal harm
03/13/2008	Have enough outside airflow.	Pattern	Potential for minimal harm
03/13/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
03/13/2008	Have a detailed, written plan for disasters and emergencies.	Widespread	Potential for minimal harm
03/13/2008	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm

Have you or someone you know become a victim of nursing home abuse or neglect? If so, contact one of our experienced nursing home lawyers today. Help End Nursing Home Abuse

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