POMONA VISTA CARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/16/2009	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
11/16/2009	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
11/16/2009	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
11/12/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
11/12/2009	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
11/12/2009	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.	Isolated	Minimal harm or potential for actual harm
11/12/2009	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
11/12/2009	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
11/12/2009	Provide bedrooms that don't allow residents to see each other when privacy is needed.	Isolated	Minimal harm or potential for actual harm
09/07/2008	Tell the resident completely about his or her health status.	Pattern	Potential for minimal harm
09/07/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
09/07/2008	Provide activities to meet the needs of each resident.	Pattern	Potential for minimal harm
09/07/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Potential for minimal harm
09/07/2008	Do a new assessment after any major change in a resident's physical or mental health.	Pattern	Potential for minimal harm
09/07/2008	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Potential for minimal harm
09/07/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Potential for minimal harm
09/07/2008	Give professional services that meet a professional standard of quality.	Pattern	Potential for minimal harm
09/07/2008	Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home.	Pattern	Potential for minimal harm
09/07/2008	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
09/07/2008	Train all employees on what to do in an emergency.	Widespread	Potential for minimal harm
08/03/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
08/03/2007	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal harm
08/03/2007	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
08/03/2007	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
07/03/2007	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	Minimal harm or potential for actual harm
07/03/2007	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
07/03/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
07/03/2007	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
07/03/2007	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
07/03/2007	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
07/03/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
07/03/2007	post nurse staffing information.	Pattern	Potential for minimal harm
07/03/2007	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
07/03/2007	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
07/03/2007	Train all employees on what to do in an emergency.	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