EDGEMOOR HOSPITAL

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for California are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 08/20/2010.

Administration

Make Sure That Nurse Aides Show They Have the Skills to Be Able to Care for Residents. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Keep Accurate and Appropriate Medical Records. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Have a Detailed, Written Plan for Disasters and Emergencies. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Train All Employees on What to Do in an Emergency. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Train All Employees on What to Do in an Emergency. Inspection Date: 08/28/2009 Correction Date: 09/21/2009
Have a Detailed, Written Plan for Disasters and Emergencies. Inspection Date: 08/20/2010 Correction Date: 09/18/2010

Environmental

Provide Needed Housekeeping and Maintenance. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Have a Program to Keep Infection from Spreading. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Have a Program to Keep Infection from Spreading. Inspection Date: 08/28/2009 Correction Date: 09/21/2009
Make Sure That the Nursing Home Area is Safe, Easy to Use, Clean and Comfortable. Inspection Date: 08/28/2009 Correction Date: 09/21/2009
Have a Program to Keep Infection from Spreading. Inspection Date: 08/20/2010 Correction Date: 09/18/2010

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 08/28/2009 Correction Date: 09/21/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 08/20/2010 Correction Date: 09/18/2010

Pharmacy Service

Properly Mark Drugs and Other Similar Products. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 08/28/2009 Correction Date: 09/21/2009
Properly Mark Drugs and Other Similar Products. Inspection Date: 08/28/2009 Correction Date: 09/21/2009
Properly Mark Drugs and Other Similar Products. Inspection Date: 08/20/2010 Correction Date: 09/18/2010

Quality Care

Give Professional Services That Meet a Professional Standard of Quality. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Give Professional Services That Meet a Professional Standard of Quality. Inspection Date: 08/28/2009 Correction Date: 09/21/2009

Resident Assessment

Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 08/28/2009 Correction Date: 09/21/2009

Resident Rights

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. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Send and Promptly Deliver Unopened Mail to Residents. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 07/24/2008 Correction Date: 09/01/2008
Send and Promptly Deliver Unopened Mail to Residents. Inspection Date: 08/28/2009 Correction Date: 09/21/2009
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 08/20/2010 Correction Date: 09/18/2010
Provide Services to Meet the Needs and Preferences of Each Resident. Inspection Date: 08/20/2010 Correction Date: 09/18/2010

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Edgemoor Hospital had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 09/02/2010.

Automatic Sprinkler Systems

Properly Working Alarms on Sprinkler Valves. Inspection Date: 08/06/2008 Correction Date: 08/29/2008
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 08/06/2008 Correction Date: 08/29/2008
Portable Fire Extinguishers. Inspection Date: 08/06/2008 Correction Date: 08/29/2008
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 08/27/2009 Correction Date: 09/16/2009
Portable Fire Extinguishers. Inspection Date: 08/27/2009 Correction Date: 09/16/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 09/02/2010 Correction Date: 09/23/2010

Building Construction

Approved Construction Type or Materials. Inspection Date: 08/27/2009 Correction Date: 09/16/2009

Building Service Equipment

Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions. Inspection Date: 08/06/2008 Correction Date: 08/29/2008
Properly Protected Cooking Facilities. Inspection Date: 08/06/2008 Correction Date: 08/29/2008
Properly Protected Cooking Facilities. Inspection Date: 09/02/2010 Correction Date: 09/23/2010

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke. Inspection Date: 08/06/2008 Correction Date: 08/29/2008
Corridor and Hallway Doors That Block Smoke. Inspection Date: 08/27/2009 Correction Date: 09/16/2009
Corridor and Hallway Doors That Block Smoke. Inspection Date: 09/02/2010 Correction Date: 09/23/2010

Electrical

Properly Installed Electrical Wiring and Equipment. Inspection Date: 08/06/2008 Correction Date: 08/29/2008
Properly Installed Electrical Wiring and Equipment. Inspection Date: 08/27/2009 Correction Date: 09/16/2009

Fire Alarm Systems

An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems. Inspection Date: 08/06/2008 Correction Date: 08/29/2008
A Fire Alarm System That Can Be Heard Throughout the Facility. Inspection Date: 08/27/2009 Correction Date: 09/16/2009

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 08/06/2008 Correction Date: 08/29/2008

Illumination and Emergency Power

Properly Located and Lighted "Exit" Signs. Inspection Date: 08/06/2008 Correction Date: 08/29/2008

Smoke Compartmentation and Control

Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes. Inspection Date: 08/06/2008 Correction Date: 08/29/2008