KERN VALLEY HEALTHCARE DISTRICT DP SNF (LAKE ISABELLA, CA) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	21.3%
California:	13.1%

Percent of long-stay residents who self-report moderate to severe pain

This Nursing Home:	7.9%
California:	8.9%

Percent of long-stay residents who lose too much weight

Here:	3.8%
California:	6.3%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

This Nursing Home:	8.8%
State:	4.0%

Percent of long-stay residents with a urinary tract infection

Here:	7.7%
California:	6.7%

Percent of long-stay residents experiencing one or more falls with major injury

This Nursing Home:	5.6%
State:	1.6%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	96.3%
California:	93.0%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	88.9%
California:	94.0%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	24.5%
State:	19.0%

Process of Care

Heart Attack

Average number of minutes before outpatients with chest pain or possible heart attack got an ECG

This Nursing Home:	42
California:	9

Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival

This Nursing Home:	86.0%
California:	97.2%

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)

This Nursing Home:	54.0%
California:	98.9%

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

This Nursing Home:	90.0%
California:	96.1%

Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics

Here:	75.0%
California:	96.7%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	77.0%
California:	98.1%

Percent of Patients Given the Most Appropriate Initial Antibiotic(s)

This Nursing Home:	69.0%
California:	95.9%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	95.0%
State:	94.3%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	80.0%
State:	95.8%

Outcome of Care

30-Day Mortality Rates from Heart Failure

Here:	10.7%
California:	10.9%

30-Day Mortality Rates from Pneumonia

This Nursing Home:	11.3%
State:	11.7%

30-Day Readmission Rates from Heart Failure

This Nursing Home:	25.0%
State:	24.4%

30-Day Readmission Rates from Pneumonia

This Nursing Home:	18.2%
California:	18.3%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.480
California:	0.748

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.770
State:	0.900

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.260
California:	1.608

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.020
State:	0.118

Number Therapy Hours Per Resident Per Day

Here:	0.020
State:	0.126

Use of Medical Imaging

Outpatient CT scans of the abdomen that were combination (double) scans.

Here:	0.563%
California:	0.170%

Outpatients with brain CT scans who got a sinus CT scan at the same time

This Nursing Home:	0.700%
California:	1.898%

Complaint Deficiency

Approved construction type or materials
- Harm: Potential for minimal harm
- Scope: Some
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Potential for minimal harm
- Scope: Some
Proper backup exit lighting
- Harm: Potential for minimal harm
- Scope: Some
Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay
- Harm: Potential for minimal harm
- Scope: Some
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Some
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Potential for minimal harm
- Scope: Some
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Some
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Some
Signs that state that exit doors are to be kept closed
- Harm: Potential for minimal harm
- Scope: Some
Hire sufficient dietary support personnel
- Harm: Potential for minimal harm
- Scope: Some
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Some
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Some
Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide activities to meet the interests and needs of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure each resident receives an accurate assessment by a qualified health professional
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that a working call system is available in each resident's room or bathroom and bathing area
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Other fire safety features required by fire safety codes
- Harm: Potential for minimal harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Back-up procedures in place for a faulty automatic sprinkler system
- Harm: Potential for minimal harm
- Scope: Many
Provide activities to meet the interests and needs of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide a safe, clean, comfortable and homelike environment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Keep all essential equipment working safely
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Train all employees on what to do in an emergency, and carry out announced staff drills
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Restrictions on the use of highly flammable materials
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Reasonably accommodate the needs and preferences of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide activities to meet the interests and needs of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have enough nurses to care for every resident in a way that maximizes the resident's well being
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Few
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Potential for minimal harm
- Scope: Many
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly maintained smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few

KERN VALLEY HEALTHCARE DISTRICT DP SNF - LAKE ISABELLA, CA