ST JUDE CARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/28/2011	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
01/28/2011	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
01/28/2011	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
01/28/2011	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Isolated	Minimal harm or potential for actual harm
01/28/2011	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
01/28/2011	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
01/28/2011	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
01/28/2011	portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
01/28/2011	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
01/28/2011	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
01/28/2011	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
01/28/2011	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
01/13/2011	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Provide bedrooms that don't allow residents to see each other when privacy is needed.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) an adequate bed; 4) furniture that meets the resident's needs; or 5) enough closet space.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Set up or keep a group of people to review and ensure quality.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Protect a resident's right to refuse some types of non-requested transfers within the nursing home.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Keep sound levels comfortable.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
01/13/2011	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
01/13/2011	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
01/13/2011	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.	Isolated	Minimal harm or potential for actual harm
01/13/2011	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
01/13/2011	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
01/12/2010	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
01/12/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
01/12/2010	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
01/12/2010	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
01/12/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/12/2010	a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
01/12/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
01/07/2010	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
01/07/2010	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
01/07/2010	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
01/07/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
01/07/2010	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
01/07/2010	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
01/07/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Screen residents when they are first admitted to send them to an area with special care for people with developmental disabilities or mental illness, if needed.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/07/2010	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
01/07/2010	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
01/07/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
01/07/2010	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
01/07/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
01/07/2010	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
01/07/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
01/07/2010	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
01/22/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
01/22/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
01/22/2009	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Potential for minimal harm
01/12/2009	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.	Pattern	Minimal harm or potential for actual harm
01/12/2009	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Immediate jeopardy to resident health or safety
01/12/2009	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
01/12/2009	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Assess the resident when the resident enters the nursing home, in a timely manner.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Do an assessment of the resident every year.	Isolated	Minimal harm or potential for actual harm
01/12/2009	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
01/12/2009	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Potential for minimal harm
01/12/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
01/12/2009	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
01/12/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
01/12/2009	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.	Pattern	Minimal harm or potential for actual harm
01/12/2009	Make sure that residents are safe from serious medication errors.	Isolated	Immediate jeopardy to resident health or safety
01/12/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Use a registered nurse at least 8 hours a day, 7 days a week.	Widespread	Minimal harm or potential for actual harm
01/12/2009	post nurse staffing information.	Pattern	Potential for minimal harm
01/12/2009	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
01/12/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
01/12/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
01/12/2009	Set up or keep a group of people to review and ensure quality.	Widespread	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