SUNRAY HEALTHCARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/28/2010	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Isolated	Minimal harm or potential for actual harm
06/28/2010	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
06/28/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
06/28/2010	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
06/28/2010	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
06/28/2010	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
06/28/2010	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
06/28/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
06/28/2010	fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
06/28/2010	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
06/28/2010	properly installed hallway dispensers for alcohol-based hand rub.	Widespread	Minimal harm or potential for actual harm
06/28/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
06/27/2010	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
06/27/2010	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
06/27/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
06/27/2010	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
06/27/2010	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
06/27/2010	post nurse staffing information.	Widespread	Potential for minimal harm
06/27/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
06/27/2010	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
06/27/2010	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
06/27/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
03/12/2009	properly located and lighted "Exit" signs.	Widespread	Minimal harm or potential for actual harm
03/12/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
03/12/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
03/12/2009	restrictions on the use of highly flammable materials.	Widespread	Potential for minimal harm
03/12/2009	restrictions on the use of flammable curtains.	Widespread	Minimal harm or potential for actual harm
03/12/2009	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
03/01/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
03/01/2009	Provide services to meet the needs and preferences of each resident.	Widespread	Potential for minimal harm
03/01/2009	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
03/01/2009	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
03/01/2009	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
03/01/2009	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
11/20/2007	Provide enough notice before discharging or transferring a resident.	Isolated	Minimal harm or potential for actual harm
11/20/2007	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
11/20/2007	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
11/20/2007	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Potential for minimal harm
11/20/2007	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
11/20/2007	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
11/20/2007	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
11/20/2007	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.	Isolated	Minimal harm or potential for actual harm
11/20/2007	Get rid of garbage properly.	Widespread	Potential for minimal harm
11/20/2007	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
11/20/2007	Properly mark drugs and other similar products.	Pattern	Potential for minimal harm
11/20/2007	Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
11/20/2007	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Isolated	Minimal harm or potential for actual harm
11/20/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
11/20/2007	Have enough outside airflow.	Widespread	Potential for minimal harm
11/20/2007	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Minimal harm or potential for actual harm
11/20/2007	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
11/19/2007	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
11/19/2007	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
11/19/2007	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
11/19/2007	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
11/19/2007	fire safety features required by current fire safety codes.	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