SOUTHLAND CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
09/03/2010	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
09/03/2010	Assess the resident when the resident enters the nursing home, in a timely manner.	Isolated	Minimal harm or potential for actual harm
09/03/2010	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
09/03/2010	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Minimal harm or potential for actual harm
09/03/2010	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
09/03/2010	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
09/03/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
09/03/2010	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
09/03/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
09/03/2010	Have a program to keep infection from spreading.	Widespread	Potential for minimal harm
09/03/2010	Keep all essential equipment working safely.	Widespread	Potential for minimal harm
09/03/2010	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
09/03/2010	fire-resistant interior walls.	Isolated	Minimal harm or potential for actual harm
09/03/2010	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
09/03/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
09/03/2010	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
09/03/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
09/03/2010	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
06/16/2009	fire-resistant room wall surfaces.	Isolated	Minimal harm or potential for actual harm
06/16/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
06/16/2009	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
06/16/2009	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
06/16/2009	properly installed hallway dispensers for alcohol-based hand rub.	Pattern	Minimal harm or potential for actual harm
06/05/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
06/05/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
06/05/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
06/05/2009	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
04/03/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
04/03/2008	properly working alarms on sprinkler valves.	Widespread	Potential for minimal harm
04/03/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Potential for minimal harm
04/03/2008	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home.	Pattern	Potential for minimal harm
04/02/2008	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
04/02/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Potential for minimal harm
04/02/2008	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Give special rehabilitation by skilled workers, when ordered by a doctor.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
04/02/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
04/02/2008	Keep accurate and appropriate medical records.	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