SHERMAN OAKS HEALTH & REHAB CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/07/2011	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
03/07/2011	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
03/07/2011	properly working alarms on sprinkler valves.	Widespread	Potential for minimal harm
03/07/2011	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
03/07/2011	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
03/02/2011	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
03/02/2011	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
03/02/2011	Keep temperature levels comfortable and safe.	Pattern	Minimal harm or potential for actual harm
03/02/2011	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
03/02/2011	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
03/02/2011	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
03/02/2011	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
03/02/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
03/02/2011	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
03/02/2011	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
03/02/2011	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
03/02/2011	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
03/02/2011	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
03/02/2011	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
03/02/2011	Store, cook, and give out food in a safe and clean way.	Pattern	Potential for minimal harm
03/02/2011	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
03/02/2011	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/22/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/22/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
12/22/2009	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
12/22/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
12/22/2009	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
12/22/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
12/22/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
12/22/2009	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
12/22/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
12/22/2009	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
12/22/2009	Make sure that each resident gets help to keep vision and hearing.	Isolated	Minimal harm or potential for actual harm
12/22/2009	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
12/22/2009	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
12/22/2009	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
12/22/2009	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Potential for minimal harm
12/22/2009	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
12/22/2009	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
12/22/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Potential for minimal harm
12/22/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
12/22/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/22/2009	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
12/22/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
12/22/2009	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
12/22/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
10/01/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
10/01/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Potential for minimal harm
10/01/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
10/01/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/01/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/01/2008	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
10/01/2008	Make sure that each resident gets help to keep vision and hearing.	Pattern	Potential for minimal harm
10/01/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
10/01/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Pattern	Minimal harm or potential for actual harm
10/01/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
10/01/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/01/2008	Give each resident enough fluids to keep them healthy and prevent dehydration.	Pattern	Minimal harm or potential for actual harm
10/01/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Potential for minimal harm
10/01/2008	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
10/01/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
10/01/2008	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Potential for minimal harm
10/01/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
10/01/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
10/01/2008	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Widespread	Potential for minimal harm
10/01/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
10/01/2008	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
10/01/2008	rooms that can be unlocked from inside without a key.	Isolated	Minimal harm or potential for actual harm
10/01/2008	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
10/01/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
10/01/2008	properly sized and located linen or trash receptacles.	Widespread	Minimal harm or potential for actual harm
10/01/2008	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
10/01/2008	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
10/01/2008	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

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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