WINDSOR MANOR REHABILITATION CENTER CA DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/29/2009	approved construction type or materials.	Isolated	Minimal harm or potential for actual harm
12/29/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/29/2009	exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
12/29/2009	emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
12/29/2009	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
12/29/2009	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
12/29/2009	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
12/29/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
12/29/2009	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
12/29/2009	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
12/21/2009	Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
12/21/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
12/21/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
12/21/2009	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
12/21/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/21/2009	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
12/21/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
12/21/2009	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
12/21/2009	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
10/21/2008	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
10/21/2008	corridors or aisles that are unobstructed and are at least 8 feet in width.	Isolated	Minimal harm or potential for actual harm
10/21/2008	record of quarterly fire drills for each shift under varying conditions.	Isolated	Minimal harm or potential for actual harm
10/21/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
10/21/2008	properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
10/21/2008	restrictions on the use of highly flammable materials.	Isolated	Minimal harm or potential for actual harm
10/21/2008	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
10/21/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
10/14/2008	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
10/14/2008	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
10/14/2008	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
10/14/2008	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
10/14/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/14/2008	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
10/14/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
10/14/2008	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
10/14/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
10/14/2008	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
10/14/2008	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm
07/17/2007	corridor and hallway doors that block smoke.	Pattern	Potential for minimal harm
07/17/2007	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
07/17/2007	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
07/17/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
07/17/2007	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
07/17/2007	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
07/17/2007	automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
07/17/2007	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal harm
07/17/2007	restrictions on the use of highly flammable materials.	Pattern	Potential for minimal harm
07/17/2007	weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
07/17/2007	properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
07/13/2007	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.	Pattern	Potential for minimal harm
07/13/2007	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Have a private telephone available for use.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Keep temperature levels comfortable and safe.	Pattern	Minimal harm or potential for actual harm
07/13/2007	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
07/13/2007	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
07/13/2007	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
07/13/2007	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.	Pattern	Minimal harm or potential for actual harm
07/13/2007	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
07/13/2007	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
07/13/2007	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
07/13/2007	Offer other nutritional food to each resident who will not eat the food served.	Pattern	Potential for minimal harm
07/13/2007	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
07/13/2007	At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Pattern	Minimal harm or potential for actual harm
07/13/2007	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Put firmly secured handrails on each side of hallways.	Pattern	Minimal harm or potential for actual harm
07/13/2007	Train all employees on what to do in an emergency.	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