WHISPERING HOPE CARE CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
04/16/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
04/16/2010	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
04/16/2010	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
04/16/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
04/16/2010	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
04/16/2010	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
04/16/2010	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
04/16/2010	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
04/16/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
04/16/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
04/16/2010	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
04/16/2010	weekly inspections and monthly testing of generators.	Pattern	Minimal harm or potential for actual harm
04/16/2010	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
04/09/2010	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.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Widespread	Minimal harm or potential for actual harm
04/09/2010	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Widespread	Minimal harm or potential for actual harm
04/09/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Protect each resident from all abuse, physical punishment, and being separated from others.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Give enough notice to the resident before changing the resident's room or roommate.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
04/09/2010	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
04/09/2010	Provide a tasty and well-balanced diet that meets the nutritional needs of each resident.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Get rid of garbage properly.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
04/09/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
04/09/2010	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
02/05/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
02/05/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
02/05/2009	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
02/05/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
02/05/2009	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
02/05/2009	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
01/23/2009	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.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
01/23/2009	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
01/23/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
01/23/2009	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
01/23/2009	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
01/23/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/23/2009	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
01/23/2009	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
01/23/2009	post nurse staffing information.	Pattern	Potential for minimal harm
01/23/2009	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
01/23/2009	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
01/23/2009	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
01/23/2009	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
01/23/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Be administered in a way that leads to the highest possible level of well being for each resident.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Follow all laws and professional standards.	Pattern	Minimal harm or potential for actual harm
01/23/2009	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Widespread	Potential for minimal harm
01/23/2009	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
01/23/2009	Set up or keep a group of people to review and ensure quality.	Pattern	Minimal harm or potential for actual harm
12/18/2007	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
12/18/2007	fire-resistant interior walls.	Isolated	Minimal harm or potential for actual harm
12/18/2007	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
12/18/2007	record of quarterly fire drills for each shift under varying conditions.	Pattern	Potential for minimal harm
12/18/2007	properly working alarms on sprinkler valves.	Isolated	Minimal harm or potential for actual harm
12/18/2007	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Minimal harm or potential for actual harm
12/18/2007	restrictions on the use of highly flammable materials.	Pattern	Minimal harm or potential for actual harm
12/13/2007	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Minimal harm or potential for actual harm
12/13/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Potential for minimal harm
12/13/2007	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Potential for minimal harm
12/13/2007	Keep adequate and comfortable lighting in all areas.	Pattern	Minimal harm or potential for actual harm
12/13/2007	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
12/13/2007	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
12/13/2007	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
12/13/2007	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
12/13/2007	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
12/13/2007	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
12/13/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/13/2007	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
12/13/2007	Follow all laws and professional standards.	Isolated	Minimal harm or potential for actual harm
12/13/2007	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
12/13/2007	Have a detailed, written plan for disasters and emergencies.	Pattern	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