TEMPLE CITY CONVALESCENT HOSP CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/21/2010	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
06/21/2010	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
06/21/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
06/21/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
06/21/2010	properly protected cooking facilities.	Pattern	Potential for minimal harm
06/21/2010	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
06/21/2010	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
06/21/2010	a separate and independent backup electrical power source.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
06/18/2010	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
06/18/2010	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
06/18/2010	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.	Pattern	Minimal harm or potential for actual harm
06/18/2010	post nurse staffing information.	Widespread	Potential for minimal harm
06/18/2010	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Offer other nutritional food to each resident who will not eat the food served.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Properly mark drugs and other similar products.	Widespread	Potential for minimal harm
06/18/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
06/18/2010	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
06/18/2010	Keep accurate and appropriate medical records.	Widespread	Potential for minimal harm
03/23/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
03/19/2009	Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion.	Isolated	Minimal harm or potential for actual harm
03/19/2009	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.	Isolated	Minimal harm or potential for actual harm
02/15/2008	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Potential for minimal harm
02/15/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
02/15/2008	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Potential for minimal harm
02/15/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
02/15/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
02/15/2008	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
02/15/2008	Use a registered nurse at least 8 hours a day, 7 days a week.	Pattern	Minimal harm or potential for actual harm
02/15/2008	post nurse staffing information.	Pattern	Potential for minimal harm
02/15/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
02/15/2008	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
02/15/2008	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
02/15/2008	Have a detailed, written plan for disasters and emergencies.	Pattern	Potential for minimal harm
02/14/2008	fire-resistant room wall surfaces.	Pattern	Potential for minimal harm
02/14/2008	signs that state that exit doors are to be kept closed.	Pattern	Potential for minimal harm
02/14/2008	fire safety features required by current fire safety codes.	Widespread	Potential for minimal harm
02/14/2008	weekly inspections and monthly testing of generators.	Widespread	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