SAINT VINCENT HEALTHCARE CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/16/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
11/16/2010	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
11/16/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
11/16/2010	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
11/16/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
11/16/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
11/16/2010	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
11/16/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
11/16/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
11/16/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
11/16/2010	Provide bedrooms that hold no more than 4 residents per room.	Widespread	Potential for minimal harm
11/16/2010	Provide rooms that are big enough for each resident.	Widespread	Potential for minimal harm
11/16/2010	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
11/16/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
11/16/2010	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
11/16/2010	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
11/09/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
11/09/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
08/19/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
08/17/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
08/17/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
08/17/2009	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
08/17/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
08/17/2009	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
08/17/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
08/17/2009	post nurse staffing information.	Widespread	Potential for minimal harm
08/17/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
08/17/2009	Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
08/17/2009	Provide bedrooms that hold no more than 4 residents per room.	Pattern	Potential for minimal harm
08/17/2009	Provide rooms that are big enough for each resident.	Widespread	Potential for minimal harm
08/17/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
08/17/2009	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
08/17/2009	Have a detailed, written plan for disasters and emergencies.	Isolated	Minimal harm or potential for actual harm
06/24/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
06/24/2008	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
06/24/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
06/24/2008	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
06/24/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
06/24/2008	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
06/24/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
06/24/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
06/24/2008	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
06/24/2008	a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
06/24/2008	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
06/24/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
06/24/2008	fire safety features required by current fire safety codes.	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