OLYMPIA CONVALESCENT HOSPITAL CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
05/20/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
05/20/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
05/20/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
05/20/2010	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
05/20/2010	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
05/20/2010	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
05/20/2010	a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
05/20/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
05/20/2010	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
05/20/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
05/20/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
05/20/2010	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
05/20/2010	restrictions on the use of highly flammable materials.	Widespread	Minimal harm or potential for actual harm
05/20/2010	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
05/20/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
05/16/2010	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
05/16/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
05/16/2010	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
05/16/2010	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
05/16/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
05/16/2010	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
05/16/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
05/16/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
05/16/2010	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
05/16/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
05/16/2010	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
05/16/2010	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
05/16/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
05/16/2010	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Pattern	Minimal harm or potential for actual harm
05/16/2010	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
05/16/2010	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
05/16/2010	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
05/16/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
05/16/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
05/16/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
05/16/2010	Put firmly secured handrails on each side of hallways.	Isolated	Minimal harm or potential for actual harm
05/16/2010	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
02/18/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Pattern	Potential for minimal harm
02/18/2009	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
02/18/2009	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Potential for minimal harm
02/18/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
02/18/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Potential for minimal harm
02/12/2009	fire-resistant room wall surfaces.	Pattern	Potential for minimal harm
02/12/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/12/2009	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
02/12/2009	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
02/12/2009	no-smoking signs where oxygen is used.	Isolated	Minimal harm or potential for actual harm
02/12/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/24/2007	Make sure that each resident has the right to join in social, religious, and community activities.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
10/24/2007	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
10/24/2007	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.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Store, cook, and give out food in a safe and clean way.	Pattern	Potential for minimal harm
10/24/2007	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
10/24/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Isolated	Minimal harm or potential for actual harm
10/24/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
10/24/2007	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
10/24/2007	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
10/18/2007	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
10/18/2007	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
10/18/2007	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
10/18/2007	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
10/18/2007	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
10/18/2007	properly installed electrical wiring and equipment.	Isolated	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