THE TERRACES OF LOS GATOS CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/15/2010	restrictions on the use of flammable curtains.	Isolated	Minimal harm or potential for actual harm
12/15/2010	a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
12/15/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/15/2010	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
12/15/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
12/15/2010	restrictions on the use of highly flammable materials.	Pattern	Minimal harm or potential for actual harm
12/15/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
12/15/2010	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
12/15/2010	back-up procedures in place for a faulty automatic sprinkler system.	Isolated	Minimal harm or potential for actual harm
12/13/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/13/2010	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
12/13/2010	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
12/13/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
12/13/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/13/2010	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
12/13/2010	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
12/13/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
12/13/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/13/2010	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
12/13/2010	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
12/13/2010	Keep each resident's personal and medical records private and confidential.	Pattern	Potential for minimal harm
12/13/2010	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
12/13/2010	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
01/14/2010	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
01/14/2010	properly maintained smoke detectors.	Pattern	Minimal harm or potential for actual harm
01/14/2010	restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
01/14/2010	properly installed hallway dispensers for alcohol-based hand rub.	Widespread	Minimal harm or potential for actual harm
01/11/2010	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
01/11/2010	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
01/11/2010	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
01/11/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
01/11/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
01/11/2010	Provide food in a way that meets a resident's needs.	Isolated	Minimal harm or potential for actual harm
01/11/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
01/11/2010	Get rid of garbage properly.	Widespread	Minimal harm or potential for actual harm
01/11/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
01/11/2010	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/11/2010	Keep accurate and appropriate medical records.	Widespread	Minimal harm or potential for actual harm
04/20/2009	Provide written records when a resident is transferred or discharged.	Isolated	Minimal harm or potential for actual harm
04/20/2009	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
04/20/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/20/2009	Store, cook, and give out food in a safe and clean way.	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