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PACIFICA HOSPITAL OF THE VALLEY - SUN VALLEY, CA

 



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Address
9449 SAN FERNANDO ROAD
SUN VALLEY, CA, 91352
Phone (make sure to verify first before calling): (818) 767-3310

Number of Certified Beds: 98
Total Number of Residents: 62
Percent of Occupied Beds: 63%
Sprinkler Status: Partially Sprinklered
Program Participation: Medicare and Medicaid
Type of Ownership: For profit - Corporation
Located Within a Hospital?: Yes
Multi Nursing Home Ownership?: No
Resident and Family Councils: None
Continuing Care Retirement Community?: No
Quality Indicator Survey?: No
Special Focus Facility?: No
Type: Skilled Nursing Facilities


Overall Star Rating: 1 Star
Health Inspections Star Rating: 1 Star
Nurse Staffing Star Rating: 4 Stars
Quality Measures Star Rating: 1 Star
RN Only Star Rating: 4 Stars

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Atherosclerosis without Major Complications
Average Covered Charges
Here:

$13,468
California:

$28,823
Average Total Payments
This Nursing Home:

$6,062
California:

$4,913
Number of discharges: 16
This Nursing Home:

2.04%
State:

0.40%
Cellulitis without Major Complications
Average Covered Charges
This Nursing Home:

$13,716
California:

$36,707
Average Total Payments
Here:

$8,720
California:

$7,245
Number of discharges: 23
This Nursing Home:

2.93%
California:

2.08%
Chest Pain
Average Covered Charges
This Nursing Home:

$11,323
California:

$29,034
Average Total Payments
Here:

$5,766
California:

$4,742
Number of discharges: 25
This Nursing Home:

3.18%
California:

2.11%
Chronic Obstructive Pulmonary Disease without Complications
Average Covered Charges
Here:

$18,186
State:

$35,163
Average Total Payments
This Nursing Home:

$7,508
State:

$6,206
Number of discharges: 20
This Nursing Home:

2.55%
State:

1.11%
Diabetes with Complications
Average Covered Charges
This Nursing Home:

$14,432
State:

$38,964
Average Total Payments
Here:

$8,623
State:

$7,470
Number of discharges: 12
Here:

1.53%
California:

0.69%
Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications
Average Covered Charges
Here:

$13,794
California:

$36,899
Average Total Payments
Here:

$7,461
California:

$6,233
Number of discharges: 29
This Nursing Home:

3.69%
State:

3.09%
G.I. Hemorrhage with Complications
Average Covered Charges
Here:

$25,345
State:

$46,039
Average Total Payments
This Nursing Home:

$10,692
State:

$8,685
Number of discharges: 16
This Nursing Home:

2.04%
State:

1.95%
Heart Failure and Shock with Complications
Average Covered Charges
This Nursing Home:

$19,288
State:

$47,292
Average Total Payments
This Nursing Home:

$10,564
State:

$8,831
Number of discharges: 17
Here:

2.17%
California:

2.91%
Heart Failure and Shock without Complications
Average Covered Charges
This Nursing Home:

$13,085
State:

$32,995
Average Total Payments
This Nursing Home:

$7,138
State:

$5,851
Number of discharges: 17
Here:

2.17%
State:

1.02%
Kidney and Urinary Tract Infections without Major Complications
Average Covered Charges
Here:

$14,163
California:

$36,114
Average Total Payments
This Nursing Home:

$7,658
State:

$6,728
Number of discharges: 21
Here:

2.68%
California:

2.98%
Misc Disorders of Nutrition, Metabolism, Fluids or Electrolytes without Major Complications
Average Covered Charges
This Nursing Home:

$12,963
State:

$32,446
Average Total Payments
This Nursing Home:

$7,113
State:

$5,975
Number of discharges: 27
This Nursing Home:

3.44%
California:

2.21%
Psychoses
Average Covered Charges
This Nursing Home:

$14,833
California:

$24,503
Average Total Payments
Here:

$9,622
State:

$8,916
Number of discharges: 418
Here:

53.25%
State:

2.32%
Respiratory System Diagnosis with Ventilator Support 96+ Hours
Average Covered Charges
This Nursing Home:

$98,849
California:

$262,024
Average Total Payments
Here:

$45,380
California:

$48,700
Number of discharges: 13
Here:

1.66%
State:

0.44%
Seizures without Major Complications
Average Covered Charges
This Nursing Home:

$14,320
California:

$38,752
Average Total Payments
Here:

$7,738
California:

$6,932
Number of discharges: 12
This Nursing Home:

1.53%
State:

0.59%
Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours
Average Covered Charges
This Nursing Home:

$91,452
California:

$277,564
Average Total Payments
This Nursing Home:

$46,004
California:

$53,075
Number of discharges: 19
This Nursing Home:

2.42%
State:

0.64%
Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with Major Complications
Average Covered Charges
Here:

$29,271
State:

$90,173
Average Total Payments
Here:

$19,174
State:

$16,748
Number of discharges: 22
Here:

2.80%
State:

7.21%
Signs and Symptoms without Major Complications
Average Covered Charges
This Nursing Home:

$13,038
California:

$35,628
Average Total Payments
This Nursing Home:

$6,981
State:

$6,112
Number of discharges: 11
Here:

1.40%
California:

0.53%
Simple Pneumonia and Pleurisy with Complications
Average Covered Charges
This Nursing Home:

$23,681
California:

$48,755
Average Total Payments
This Nursing Home:

$10,218
State:

$8,695
Number of discharges: 17
This Nursing Home:

2.17%
State:

2.75%
Simple Pneumonia and Pleurisy without Complications
Average Covered Charges
Here:

$20,081
State:

$34,477
Average Total Payments
This Nursing Home:

$7,391
State:

$5,838
Number of discharges: 17
Here:

2.17%
California:

0.97%
Syncope and Collapse
Average Covered Charges
Here:

$12,045
State:

$37,038
Average Total Payments
This Nursing Home:

$7,465
State:

$6,233
Number of discharges: 21
Here:

2.68%
California:

1.60%
Transient Ischemia
Average Covered Charges
This Nursing Home:

$13,365
California:

$37,396
Average Total Payments
This Nursing Home:

$7,615
California:

$6,120
Number of discharges: 12
This Nursing Home:

1.53%
State:

0.94%

Employment Full-Time Equivalent

Administrative Staff - Part Time: 0.57
Food Service Personnel - Full Time: 1.14
Housekeeping Personnel - Full Time: 4.11
Licensed Practical/ Vocational Nurses - Full Time: 90.86
Licensed Practical/ Vocational Nurses - Part Time: 2.06
Medical Directors - Under Contract: 0.86
Mental Health Services Personnel - Under Contract: 0.11
Occupational Therapy Aides - Full Time: 1.14
Registered Nurses - Full Time: 18.00
Rn Director Of Nursing - Full Time: 1.14
Social Workers - Full Time: 3.43
Activities Professionals - Full Time: 1.14
Dentists - Under Contract: 0.11
Dietitians - Part Time: 0.86
Nurses With Administrative Duties - Part Time: 0.57
Occupational Therapists - Part Time: 0.86
Physical Therapists - Part Time: 0.86
Podiatrists - Under Contract: 0.17
Nurse Aides In Training - Full Time: 4.80
Other Physicians - Under Contract: 0.29
Registered Nurses - Part Time: 1.94
Speech Pathologists - Part Time: 0.57
Pharmacists - Part Time: 1.14

Provided Services

  • Activities Services Are Provided Onsite To Residents
  • Administration And Storage Of Blood Services Are Provided Onsite To Residents
  • Clinical Laboratory Services Are Provided Onsite To Residents
  • Dental Services Are Provided Onsite To Residents
  • Diagnostic Xray Services Are Provided Onsite To Residents
  • Dietary Services Are Provided Onsite To Residents
  • Housekeeping Services Are Provided Onsite To Residents
  • Mental Health Services Are Provided Onsite To Residents
  • Nursing Services Are Provided Onsite To Residents
  • Occupational Therapy Services Are Provided Onsite To Residents
  • Pharmacy Services Are Provided Onsite To Residents
  • Physical Therapy Services Are Provided Onsite To Residents
  • Physician Services Are Provided Onsite To Residents
  • Podiatry Services Are Provided Onsite To Residents
  • Social Work Services Are Provided Onsite To Residents
  • Speech/Language Pathology Services Are Provided Onsite To Residents
  • Therapeutic Recreation Specialist Services Are Provided Onsite To Residents
  • Vocational Services Are Provided Offsite To Residents

Quality Measures

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

16.0%
California:

7.5%
Percent of long-stay residents who have had a catheter inserted and left in their bladder
Here:

10.3%
State:

4.0%
Percent of long-stay residents with a urinary tract infection
This Nursing Home:

8.3%
California:

6.7%
Percent of long-stay residents who have depressive symptoms
Here:

8.6%
State:

2.4%
Percent of long-stay residents who were physically restrained
Here:

14.8%
California:

3.6%
Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine
Here:

98.3%
State:

93.0%
Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine
Here:

95.1%
California:

94.0%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine
This Nursing Home:

45.0%
California:

79.7%
Percent of long-stay residents who received an antipsychotic medication
Here:

22.0%
California:

19.0%

Process of Care

Heart Attack

Percent of Patients Given Aspirin at Arrival
This Nursing Home:

96.0%
State:

99.3%
Average number of minutes before outpatients with chest pain or possible heart attack got an ECG
This Nursing Home:

16
State:

9
Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival
Here:

100.0%
California:

97.2%

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)
This Nursing Home:

82.0%
California:

98.9%
Percent of Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
This Nursing Home:

89.0%
California:

96.2%
Percent of Patients Given Discharge Instructions
This Nursing Home:

29.0%
State:

93.5%
Percent of Patients Given Smoking Cessation Advice/Counseling
Here:

94.0%
State:

99.4%

Pneumonia

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

92.0%
State:

96.1%
Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics
This Nursing Home:

92.0%
State:

96.7%
Percent of Patients Given Smoking Cessation Advice/Counseling
Here:

75.0%
California:

98.1%
Percent of Patients Given the Most Appropriate Initial Antibiotic(s)
Here:

88.0%
California:

95.9%
Percent of Patients Assessed and Given Influenza Vaccination
This Nursing Home:

95.0%
State:

94.3%
Percent of Patients Assessed and Given Pneumococcal Vaccination
This Nursing Home:

81.0%
California:

95.8%

Surgery

Percent of Surgery Patients given an antibiotic at the right time (within one hour before surgery) to help prevent infection
This Nursing Home:

69.0%
State:

98.1%
Percent of Surgery Patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)
Here:

74.0%
California:

96.3%
Percent of Surgery Patients who were given the right kind of antibiotic to help prevent infection
This Nursing Home:

93.0%
California:

98.2%
Percent of Surgery Patients who got treatment at right time (within 24 hours before or after surgery) to help prevent blood clot
This Nursing Home:

87.0%
State:

96.0%
Percent of Surgery Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries
This Nursing Home:

76.0%
State:

96.9%
Percent of Surgery Patients needing hair removed from the surgical area before surgery who had hair removed using a safer method
Here:

79.0%
State:

99.8%
Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)
This Nursing Home:

83.0%
California:

95.1%
Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)
This Nursing Home:

92.0%
State:

95.5%
Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal
Here:

90.0%
California:

99.6%

Outcome of Care

30-Day Mortality Rates from Heart Failure
Here:

10.8%
California:

10.9%
30-Day Mortality Rates from Pneumonia
Here:

13.6%
California:

11.7%
30-Day Readmission Rates from Heart Failure
Here:

25.4%
California:

24.4%
30-Day Readmission Rates from Pneumonia
This Nursing Home:

19.8%
State:

18.3%

Hospital Acquired Conditions

Signs of Uncontrolled Blood Sugar
Here:

0.402%
California:

0.246%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day
Here:

1.450
California:

0.748
Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day
Here:

3.590
California:

0.900
Total Number of Licensed Staff Hours Per Resident Per Day
This Nursing Home:

5.040
California:

1.608
Number of ,Certified Nurse Assistant Hours Per Resident Per Day
Here:

0.280
California:

0.118
Number Therapy Hours Per Resident Per Day
Here:

0.280
California:

0.126

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys: 300 or more
Survey Response Rate: 30%

How often did nurses communicate well with patients?

Sometimes or never
Here:

9%
California:

7%
Usually
Here:

20%
State:

21%
Always
This Nursing Home:

71%
State:

72%

How often did doctors communicate well with patients?

Sometimes or never
This Nursing Home:

7%
State:

6%
Usually
Here:

18%
California:

17%
Always
Here:

75%
State:

77%

How often did patients receive help quickly from hospital staff?

Sometimes or never
Here:

15%
State:

13%
Usually
Here:

31%
State:

28%
Always
This Nursing Home:

54%
State:

59%

How often was patients' pain well controlled?

Sometimes or never
Here:

14%
California:

8%
Usually
Here:

21%
California:

25%
Always
Here:

65%
State:

67%

How often did staff explain about medicines before giving them to patients?

Sometimes or never
Here:

27%
California:

23%
Usually
Here:

19%
State:

19%
Always
Here:

54%
California:

58%

How often were the patients' rooms and bathrooms kept clean?

Sometimes or never
Here:

9%
State:

10%
Usually
This Nursing Home:

16%
California:

21%
Always
Here:

75%
State:

69%

How often was the area around patients' rooms kept quiet at night?

Sometimes or never
This Nursing Home:

17%
State:

18%
Usually
Here:

33%
State:

33%
Always
Here:

50%
California:

49%

Were patients given information about what to do during their recovery at home?

Yes
Here:

76%
State:

81%
No
Here:

24%
California:

19%

How do patients rate the hospital overall on a scale from 0 (lowest) to 10 (highest)?

6 or lower
This Nursing Home:

12%
California:

10%
7 or 8
Here:

23%
California:

24%
9 or 10
This Nursing Home:

65%
State:

66%

Would patients recommend the hospital to friends and family?

No
Here:

10%
California:

7%
Yes, probably
This Nursing Home:

28%
California:

24%
Yes, definitely
Here:

62%
California:

69%

Complaint Deficiency

Keep each resident's personal and medical records private and confidential: Some (Potential for minimal harm)

Allow residents to easily view the results of the nursing home's most recent survey: Some (Potential for minimal harm)

Reasonably accommodate the needs and preferences of each resident: Few (Minimal harm or potential for actual harm)

Provide housekeeping and maintenance services: Some (Minimal harm or potential for actual harm)

Maintain comfortable and safe temperature levels: Some (Minimal harm or potential for actual harm)

Conduct initial and periodic assessments of each resident's functional capacity: Few (Minimal harm or potential for actual harm)

Check and assess each resident's assessment at least every 3 months: Some (Potential for minimal harm)

Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay: Some (Potential for minimal harm)

Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function: Few (Minimal harm or potential for actual harm)

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards: Few (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Some (Minimal harm or potential for actual harm)

Make sure that a working call system is available in each resident's room or bathroom and bathing area: Some (Potential for minimal harm)

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: Many (Minimal harm or potential for actual harm)

Put firmly secured handrails on each side of hallways: Some (Potential for minimal harm)

Keep accurate, complete and organized clinical records on each resident that meet professional standards: Few (Minimal harm or potential for actual harm)

Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action: Some (Potential for minimal harm)

Fire-resistant room wall surfaces: Few (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Few (Minimal harm or potential for actual harm)

Proper stairway enclosures and vertical shafts: Many (Minimal harm or potential for actual harm)

Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour: Some (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Few (Minimal harm or potential for actual harm)

Corridors or aisles that are unobstructed and are at least 8 feet in width: Few (Minimal harm or potential for actual harm)

Properly located and lighted Exit signs: Few (Minimal harm or potential for actual harm)

Record of quarterly fire drills for each shift under varying conditions: Few (Minimal harm or potential for actual harm)

Properly working alarms on sprinkler valves: Many (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Some (Minimal harm or potential for actual harm)

Properly protected cooking facilities: Few (Minimal harm or potential for actual harm)

Other fire safety features required by fire safety codes: Few (Minimal harm or potential for actual harm)

A properly installed master alarm panel: Few (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Few (Minimal harm or potential for actual harm)

Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors: Some (Minimal harm or potential for actual harm)

Signs that state that exit doors are to be kept closed: Few (Minimal harm or potential for actual harm)

Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour: Few (Minimal harm or potential for actual harm)

Smoke barrier doors that can resist smoke for at least 20 minutes: Few (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Few (Minimal harm or potential for actual harm)

Record of quarterly fire drills for each shift under varying conditions: Some (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Few (Minimal harm or potential for actual harm)

Restrictions on the use of portable space heaters: Some (Minimal harm or potential for actual harm)

Other fire safety features required by fire safety codes: Few (Minimal harm or potential for actual harm)

Allow residents to easily view the results of the nursing home's most recent survey: Some (Potential for minimal harm)

Provide activities to meet the interests and needs of each resident: Some (Minimal harm or potential for actual harm)

Maintain comfortable and safe temperature levels: Some (Minimal harm or potential for actual harm)

Conduct initial and periodic assessments of each resident's functional capacity: Few (Minimal harm or potential for actual harm)

Provide necessary care and services to maintain the highest well being of each resident : Few (Minimal harm or potential for actual harm)

Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves: Few (Minimal harm or potential for actual harm)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Some (Minimal harm or potential for actual harm)

Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function: Some (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Few (Minimal harm or potential for actual harm)

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses: Some (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Some (Minimal harm or potential for actual harm)

Dispose of garbage and refuse properly: Few (Minimal harm or potential for actual harm)

Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist: Few (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Some (Minimal harm or potential for actual harm)

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms: Some (Potential for minimal harm)

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: Some (Minimal harm or potential for actual harm)

Have enough backup water supply for essential areas of the nursing home: Some (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Few (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Few (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Few (Minimal harm or potential for actual harm)

Record of quarterly fire drills for each shift under varying conditions: Some (Minimal harm or potential for actual harm)

An approved installation, maintenance and testing program for fire alarm systems: Few (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Few (Minimal harm or potential for actual harm)

Portable fire extinguishers: Few (Minimal harm or potential for actual harm)

Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed: Few (Minimal harm or potential for actual harm)

Heating and ventilation systems that have been properly installed according to the manufacturer's instructions: Few (Minimal harm or potential for actual harm)

Properly protected cooking facilities: Few (Minimal harm or potential for actual harm)

Other fire safety features required by fire safety codes: Few (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Some (Minimal harm or potential for actual harm)

Tell the resident completely about his or her health status, care and treatments: Few (Minimal harm or potential for actual harm)

Keep each resident's personal and medical records private and confidential: Few (Minimal harm or potential for actual harm)

Provide a safe, clean, comfortable and homelike environment: Few (Minimal harm or potential for actual harm)

Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured: Few (Minimal harm or potential for actual harm)

Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay: Some (Potential for minimal harm)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Some (Minimal harm or potential for actual harm)

Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function: Some (Minimal harm or potential for actual harm)

Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion: Some (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses: Some (Minimal harm or potential for actual harm)

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: Some (Minimal harm or potential for actual harm)

Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%: Some (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Some (Minimal harm or potential for actual harm)

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms: Some (Potential for minimal harm)

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public: Some (Minimal harm or potential for actual harm)

Keep accurate, complete and organized clinical records on each resident that meet professional standards: Some (Potential for minimal harm)

Train all employees on what to do in an emergency, and carry out announced staff drills: Some (Minimal harm or potential for actual harm)

Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action: Some (Minimal harm or potential for actual harm)

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