COMMUNITY SUBACUTE AND TRANSITIONAL CARE CENTER

Nursing Home Inspector

3003 N MARIPOSA
FRESNO, CA 93703
Fresno County
Phone: 559-459-1711
Provider Number: 055258
Last Inspection: 11/18/2016

About the Nursing Home

Number of Beds: 106
Number of Residents: 103
Beds Available: 3
Percent Occupancy: 97%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: YES

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

22

Facility
16

County
32

CA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

22

2016
60

2015
7

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

11/18/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Potential 4 12/20/2016
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 12/20/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 12/20/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 12/20/2016
 
Failed To: Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Pattern : Minimal 4 12/20/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 12/20/2016
 

10/14/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Widespread : Potential 4 12/30/2015
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 12/30/2015
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Actual 4 2/24/2016
 
Failed To: Provide adequate and comfortable lighting levels in all areas. Isolated : Minimal 3 12/30/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 12/30/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 12/30/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 12/30/2015
 
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Isolated : Minimal 3 12/30/2015
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 12/30/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 12/30/2015
 
Failed To: Provide bedrooms that don't allow residents to see each other when privacy is needed. Isolated : Minimal 3 12/30/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 12/30/2015
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern : Minimal 4 12/30/2015
 
Failed To: Provide care for each resident in a way that maintains or improves their quality of life. Pattern : Minimal 4 12/30/2015
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 12/30/2015
 
Failed To: Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. Pattern : Minimal 4 12/30/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 12/30/2015
 

9/11/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 9/30/2014
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 9/30/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

9/30/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 10/28/2016
 

12/14/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 1/4/2016
 

12/23/2014 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home. Isolated : Minimal 3 1/8/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg CA State Avg
Number of Residents 103 88.41 84.47
Registered Nurses 0.95 0.49 0.81
Licensed Practical / Vocational Nurses 2.07 0.87 1.06
Certified Nursing Assistants 2.20 2.56 2.59
Total Staff Hours 5.22 3.93 4.46

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% CA State Avg%
of high risk long-stay residents with pressure ulcers 11 5 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 97 96
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97 95 95
of long-stay residents experiencing one or more falls with major injury 0 1 1
of long-stay residents who have depressive symptoms 0 1 0
of long-stay residents who lose too much weight 3 7 5
of long-stay residents who received an antianxiety or hypnotic medication 33 21 19
of long-stay residents who received an antipsychotic medication 8 14 11
of long-stay residents who self-report moderate to severe pain 22 3 3
of long-stay residents who were physically restrained 2 0 0
of long-stay residents whose ability to move independently worsened 29 17 15
of long-stay residents whose need for help with daily activities has increased 25 13 10
of long-stay residents with a catheter inserted and left in their bladder 5 2 2
of long-stay residents with a urinary tract infection 4 3 2
of low risk long-stay residents who lose control of their bowels or bladder 27 48 44
of short-stay residents assessed and appropriately given the pneumococcal vaccine 86 91 86
of short-stay residents who had an outpatient emergency department visit 16 14 11
of short-stay residents who made improvements in function 74 67 66
of short-stay residents who newly received an antipsychotic medication 6 1 1
of short-stay residents who self-report moderate to severe pain 43 9 8
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 90 88 84
of short-stay residents who were rehospitalized after a nursing home admission 48 23 21
of short-stay residents with pressure ulcers that are new or worsened 1 47 51