SIERRA VISTA CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
03/20/2009	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
03/20/2009	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
03/20/2009	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
03/20/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
03/20/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
03/20/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
03/20/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
03/20/2009	Give or get x-rays or tests only when the resident's doctor ordered them.	Isolated	Minimal harm or potential for actual harm
03/20/2009	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
03/20/2009	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
03/18/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Potential for minimal harm
03/18/2009	proper construction of ducts through walls designed to prevent smoke passage.	Isolated	Minimal harm or potential for actual harm
03/18/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
03/18/2009	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
03/18/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
03/18/2009	weekly inspections and monthly testing of generators.	Isolated	Minimal harm or potential for actual harm
03/18/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
03/18/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
03/18/2009	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
03/18/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
03/18/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
03/18/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
03/18/2009	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
02/27/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
02/27/2008	Protect the resident from a transfer or discharge that is not wanted or needed.	Pattern	Potential for minimal harm
02/27/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
02/27/2008	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
02/27/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
02/27/2008	Develop/implement required procedures for the administration of immunizations.	Widespread	Immediate jeopardy to resident health or safety
02/27/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
02/27/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Widespread	Minimal harm or potential for actual harm
02/27/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Immediate jeopardy to resident health or safety
02/27/2008	Hire a qualified dietician.	Isolated	Minimal harm or potential for actual harm
02/27/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
02/27/2008	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Isolated	Minimal harm or potential for actual harm
02/27/2008	Put firmly secured handrails on each side of hallways.	Isolated	Minimal harm or potential for actual harm
02/27/2008	Provide bedrooms that don't allow residents to see each other when privacy is needed.	Pattern	Minimal harm or potential for actual harm
02/27/2008	Have a program to keep infection from spreading.	Widespread	Immediate jeopardy to resident health or safety
02/27/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
02/27/2008	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
02/27/2008	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
02/27/2008	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
02/27/2008	Have a detailed, written plan for disasters and emergencies.	Widespread	Minimal harm or potential for actual harm
02/27/2008	Give or get lab tests to meet the needs of residents.	Pattern	Potential for minimal harm
02/27/2008	Have licensed, certified, or registered staff to give needed services.	Isolated	Minimal harm or potential for actual harm
02/27/2008	1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator.	Widespread	Minimal harm or potential for actual harm
02/27/2008	Follow all laws and professional standards.	Widespread	Minimal harm or potential for actual harm
02/27/2008	Be administered in a way that leads to the highest possible level of well being for each resident.	Pattern	Minimal harm or potential for actual harm
02/06/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
02/06/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
02/06/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
02/06/2008	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
02/06/2008	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
02/06/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
02/06/2008	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
02/06/2008	did not have a written emergency evacuation plan.	Widespread	Potential for minimal harm
02/06/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
02/06/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
02/06/2008	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
02/06/2008	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
02/06/2008	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
02/06/2008	portable fire extinguishers.	Widespread	Potential for minimal harm
02/06/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
11/30/2006	proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm
11/30/2006	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
11/30/2006	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
11/30/2006	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
11/30/2006	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
11/30/2006	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
11/30/2006	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
11/30/2006	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
11/30/2006	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
11/30/2006	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
11/17/2006	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
11/17/2006	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
11/17/2006	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
11/17/2006	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
11/17/2006	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
11/17/2006	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
11/17/2006	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
11/17/2006	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
11/17/2006	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Pattern	Minimal harm or potential for actual harm
11/17/2006	Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection.	Pattern	Minimal harm or potential for actual harm
11/17/2006	Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
11/17/2006	Train all employees on what to do in an emergency.	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