CARONDELET HOLY CROSS 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 Arizona 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 04/16/2010.

Administration

Give or Get Lab Tests to Meet the Needs of Residents. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Keep Accurate and Appropriate Medical Records. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Train All Employees on What to Do in an Emergency. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Set Up or Keep a Group of People to Review and Ensure Quality. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Set Up or Keep a Group of People to Review and Ensure Quality. Inspection Date: 04/16/2010 Correction Date: 06/07/2010

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 02/29/2008 Correction Date: 04/25/2008
Provide Needed Housekeeping and Maintenance. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Get Rid of Garbage Properly. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Have a Program to Keep Infection from Spreading. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Keep All Essential Equipment Working Safely. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 04/16/2010 Correction Date: 06/07/2010
Have a Program to Keep Infection from Spreading. Inspection Date: 04/16/2010 Correction Date: 06/07/2010

Mistreatment

Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Inspection Date: 02/29/2008 Correction Date: 04/25/2008
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. Inspection Date: 04/16/2010 Correction Date: 06/07/2010
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Inspection Date: 04/16/2010 Correction Date: 06/07/2010

Nutrition and Dietary

Make Sure That Residents Are Well Nourished. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Provide Food in a Way That Meets a Resident's Needs. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Make Sure That the Attending Doctor Orders Special Diets. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 04/16/2010 Correction Date: 06/07/2010

Pharmacy Service

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. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Properly Mark Drugs and Other Similar Products. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
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. Inspection Date: 04/16/2010 Correction Date: 06/07/2010

Quality Care

Provide Activities to Meet the Needs of Each Resident. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Give Professional Services That Meet a Professional Standard of Quality. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Give Professional Services That Follow Each Resident's Written Care Plan. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Give Professional Services That Meet a Professional Standard of Quality. Inspection Date: 04/16/2010 Correction Date: 06/07/2010

Resident Assessment

Get Doctor Orders for the Resident's Immediate Care when Admitted. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Make Sure That Doctors Visit Residents Regularly, As Required. Inspection Date: 04/16/2010 Correction Date: 06/07/2010

Resident Rights

Keep Each Resident's Personal and Medical Records Private and Confidential. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Allow Residents to Easily See the Results of the Nursing Home's Most Recent Survey. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 03/31/2009 Correction Date: 06/23/2009
Provide Services to Meet the Needs and Preferences of Each Resident. Inspection Date: 03/31/2009 Correction Date: 06/23/2009

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 Carondelet Holy Cross 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 04/22/2010.

Automatic Sprinkler Systems

Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 04/22/2010 Correction Date: 05/18/2010

Building Service Equipment

Properly Protected Cooking Facilities. Inspection Date: 03/04/2008 Correction Date: 04/15/2008

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke. Inspection Date: 03/04/2008 Correction Date: 04/15/2008
Corridor and Hallway Doors That Block Smoke. Inspection Date: 04/22/2010 Correction Date: 05/18/2010

Electrical

Properly Installed Electrical Wiring and Equipment. Inspection Date: 03/04/2008 Correction Date: 04/15/2008
Weekly Inspections and Monthly Testing of Generators. Inspection Date: 04/22/2010 Correction Date: 05/18/2010

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 04/22/2010 Correction Date: 05/18/2010

Fire Alarm Systems

Properly Maintained Smoke Detectors. Inspection Date: 03/04/2008 Correction Date: 04/15/2008

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 04/02/2009 Correction Date: 05/05/2009

Illumination and Emergency Power

Properly Located and Lighted "Exit" Signs. Inspection Date: 03/04/2008 Correction Date: 04/15/2008

Medical Gases and Anesthetizing Areas

Proper Medical Gas Storage and Administration Areas. Inspection Date: 03/04/2008 Correction Date: 04/15/2008
Proper Medical Gas Storage and Administration Areas. Inspection Date: 04/22/2010 Correction Date: 05/18/2010

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour. Inspection Date: 04/22/2010 Correction Date: 05/18/2010
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes. Inspection Date: 04/22/2010 Correction Date: 05/18/2010

Smoking Regulations

Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed. Inspection Date: 03/04/2008 Correction Date: 04/15/2008