SANTA ROSA CONVALESCENT HOSP CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/25/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
02/25/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
02/25/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
02/25/2010	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
02/25/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
02/25/2010	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
02/25/2010	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
02/25/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
02/25/2010	weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
02/25/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
02/11/2010	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Widespread	Potential for minimal harm
02/11/2010	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
02/11/2010	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
02/11/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
02/11/2010	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
02/11/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/11/2010	Keep all essential equipment working safely.	Widespread	Minimal harm or potential for actual harm
02/10/2009	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
02/10/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
02/10/2009	no-smoking signs where oxygen is used.	Isolated	Minimal harm or potential for actual harm
02/10/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/29/2009	Keep sound levels comfortable.	Isolated	Minimal harm or potential for actual harm
01/29/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
01/29/2009	Get rid of garbage properly.	Widespread	Potential for minimal harm
01/29/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
01/29/2009	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
01/29/2009	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
01/29/2009	Train all employees on what to do in an emergency.	Widespread	Minimal harm or potential for actual harm
01/29/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/29/2008	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
01/29/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
01/29/2008	back-up procedures in place for a faulty automatic sprinkler system.	Pattern	Minimal harm or potential for actual harm
01/29/2008	an approved back-up procedure for a faulty fire alarm system.	Pattern	Minimal harm or potential for actual harm
01/17/2008	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Potential for minimal harm
01/17/2008	Make sure that residents are well nourished.	Pattern	Potential for minimal harm
01/17/2008	Provide food in a way that meets a resident's needs.	Pattern	Potential for minimal harm
01/17/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
01/17/2008	Keep all essential equipment working safely.	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