WATERS EDGE, THE CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/26/2010	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
01/26/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
01/26/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
01/26/2010	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
01/26/2010	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
01/26/2010	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
01/26/2010	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
01/26/2010	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
01/26/2010	back-up procedures in place for a faulty automatic sprinkler system.	Isolated	Minimal harm or potential for actual harm
01/26/2010	an approved back-up procedure for a faulty fire alarm system.	Isolated	Minimal harm or potential for actual harm
01/15/2010	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
01/15/2010	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
01/15/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
01/15/2010	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
01/15/2010	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
01/15/2010	Give professional services that meet a professional standard of quality.	Pattern	Potential for minimal harm
01/15/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
01/15/2010	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Isolated	Minimal harm or potential for actual harm
01/15/2010	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Widespread	Potential for minimal harm
01/15/2010	Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public.	Widespread	Minimal harm or potential for actual harm
01/15/2010	Keep all essential equipment working safely.	Widespread	Potential for minimal harm
01/15/2010	Keep accurate and appropriate medical records.	Pattern	Potential for minimal harm
01/15/2010	Have a detailed, written plan for disasters and emergencies.	Widespread	Potential for minimal harm
12/23/2008	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
12/23/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
12/23/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
12/23/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
12/23/2008	restrictions on the use of highly flammable materials.	Pattern	Minimal harm or potential for actual harm
12/23/2008	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
12/11/2008	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Pattern	Minimal harm or potential for actual harm
12/11/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/11/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Potential for minimal harm
12/11/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/11/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
12/11/2008	Have a program to keep infection from spreading.	Widespread	Potential for minimal harm
12/11/2008	Keep all essential equipment working safely.	Pattern	Potential for minimal harm
12/11/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm
10/30/2007	corridor and hallway doors that block smoke.	Widespread	Potential for minimal harm
10/30/2007	rooms that can be unlocked from inside without a key.	Isolated	Minimal harm or potential for actual harm
10/30/2007	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
10/30/2007	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
10/30/2007	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Potential for minimal harm
10/30/2007	restrictions on the use of highly flammable materials.	Isolated	Minimal harm or potential for actual harm
10/30/2007	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
10/30/2007	properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
10/30/2007	an approved back-up procedure for a faulty fire alarm system.	Widespread	Potential for minimal harm
10/30/2007	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
10/22/2007	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
10/22/2007	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.	Isolated	Minimal harm or potential for actual harm
10/22/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/22/2007	Develop a plan with the resident and family for the resident's care after leaving the nursing home.	Pattern	Potential for minimal harm
10/22/2007	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
10/22/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/22/2007	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
10/22/2007	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
10/22/2007	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
10/22/2007	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
10/22/2007	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
10/22/2007	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
10/22/2007	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
10/22/2007	Set up or keep a group of people to review and ensure quality.	Widespread	Potential for minimal harm
10/22/2007	Keep each resident's personal and medical records private and confidential.	Pattern	Potential for minimal harm
10/22/2007	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Widespread	Potential for minimal harm
10/22/2007	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal harm
10/22/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
10/22/2007	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
10/22/2007	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
10/22/2007	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
10/22/2007	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/22/2007	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
10/22/2007	Do a new assessment after any major change in a resident's physical or mental health.	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