COUNTRY VILLA RANCHO MIRAGE HEALTHCARE CTR (RANCHO MIRAGE, CA) Detailed Nursing Home Profile

Quality Measures

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

This Nursing Home:	6.7%
State:	13.1%

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

This Nursing Home:	20.1%
California:	8.9%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	19.4%
California:	7.5%

Percent of long-stay residents who lose too much weight

This Nursing Home:	2.8%
State:	6.3%

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

Here:	5.8%
California:	4.0%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	11.1%
California:	6.7%

Percent of long-stay residents who were physically restrained

Here:	2.6%
California:	3.6%

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

This Nursing Home:	82.1%
State:	93.0%

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

Here:	97.4%
State:	94.0%

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

This Nursing Home:	26.2%
State:	21.2%

Percent of short-stay residents with Pressure ulcers that are new or worsened

This Nursing Home:	1.7%
State:	1.2%

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

Here:	59.9%
State:	81.9%

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

Here:	91.0%
State:	79.7%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	1.3%
State:	2.2%

Percent of long-stay residents who received an antipsychotic medication

Here:	12.8%
State:	19.0%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.700
State:	0.748

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

This Nursing Home:	1.490
State:	0.900

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	2.180
California:	1.608

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.270
California:	0.118

Number Therapy Hours Per Resident Per Day

Here:	0.270
State:	0.126

Complaint Deficiency

A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Conduct initial and periodic assessments of each resident's functional capacity
- 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
Maintain 15 months of resident assessments in the resident's active clinical record
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies and procedures for influenza and pneumococcal immunizations
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide food in a way that meets a resident's needs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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: Many
Have a program that investigates, controls and keeps infection from spreading
- 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
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator
- 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: Few
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Record of quarterly fire drills for each shift under varying conditions
- Harm: Potential for minimal harm
- Scope: Many
Properly maintained smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
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 necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- 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: Some
Resident room doors of proper design and width
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly installed hallway dispensers for alcohol-based hand rub
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Tell the resident completely about his or her health status, care and treatments
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- 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 necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that special or therapeutic diets are ordered by the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- 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: Some
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors
- 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: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few

COUNTRY VILLA RANCHO MIRAGE HEALTHCARE CTR - RANCHO MIRAGE, CA

Quality Measures

Staff Information

Complaint Deficiency

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