SOUTHERN INYO HOSPITAL D-P SNF CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
10/19/2010	a two-hour-resistant firewall in common walls.	Pattern	Minimal harm or potential for actual harm
10/19/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
10/19/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
10/19/2010	signs that state that exit doors are to be kept closed.	Isolated	Minimal harm or potential for actual harm
10/19/2010	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
10/19/2010	properly located and lighted "Exit" signs.	Isolated	Minimal harm or potential for actual harm
10/19/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
10/19/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
10/19/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
10/19/2010	properly constructed piped-in oxygen systems.	Widespread	Minimal harm or potential for actual harm
10/19/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
10/19/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/15/2010	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
10/15/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
10/15/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
10/15/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Potential for minimal harm
10/15/2010	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Isolated	Minimal harm or potential for actual harm
10/15/2010	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
09/04/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
09/04/2009	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
09/04/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
09/04/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
09/04/2009	Keep all essential equipment working safely.	Widespread	Minimal harm or potential for actual harm
09/04/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
09/02/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
09/02/2009	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
09/02/2009	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
09/02/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Potential for minimal harm
09/02/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
09/02/2009	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
09/02/2009	did not have a written emergency evacuation plan.	Widespread	Potential for minimal harm
09/02/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
09/02/2009	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
09/02/2009	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
09/02/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
09/02/2009	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
09/02/2009	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
09/02/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
09/02/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
09/02/2009	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
09/02/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
06/05/2008	Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
06/05/2008	Have a program to keep infection from spreading.	Widespread	Immediate jeopardy to resident health or safety
06/05/2008	Put firmly secured handrails on each side of hallways.	Widespread	Minimal harm or potential for actual harm
06/05/2008	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Widespread	Minimal harm or potential for actual harm
06/05/2008	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Immediate jeopardy to resident health or safety
06/05/2008	Tell the resident completely about his or her health status.	Widespread	Immediate jeopardy to resident health or safety
06/05/2008	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
06/05/2008	Keep each resident's personal and medical records private and confidential.	Widespread	Potential for minimal harm
06/05/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
06/05/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
06/05/2008	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
06/05/2008	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
06/05/2008	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
06/05/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
06/05/2008	Keep temperature levels comfortable and safe.	Pattern	Minimal harm or potential for actual harm
06/05/2008	Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress.	Widespread	Potential for minimal harm
06/05/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Actual harm
06/05/2008	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
06/05/2008	Develop/implement required procedures for the administration of immunizations.	Widespread	Immediate jeopardy to resident health or safety
06/05/2008	Use a registered nurse at least 8 hours a day, 7 days a week.	Pattern	Immediate jeopardy to resident health or safety
06/05/2008	Make sure that residents are well nourished.	Widespread	Minimal harm or potential for actual harm
06/05/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
06/05/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Widespread	Minimal harm or potential for actual harm
06/05/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
06/05/2008	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
06/05/2008	Set up or keep a group of people to review and ensure quality.	Pattern	Actual harm
05/30/2008	approved construction type or materials.	Pattern	Potential for minimal harm
05/30/2008	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
05/30/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
05/30/2008	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
05/30/2008	an approved installation, maintenance and testing program for fire alarm systems.	Isolated	Minimal harm or potential for actual harm
05/30/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
05/30/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Isolated	Minimal harm or potential for actual harm
05/30/2008	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
05/30/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
05/30/2008	restrictions on the use of highly flammable materials.	Pattern	Potential for minimal harm
05/30/2008	properly constructed piped-in oxygen systems.	Isolated	Minimal harm or potential for actual harm
05/30/2008	weekly inspections and monthly testing of generators.	Pattern	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