ATRIUM HC & REHAB CTR OF CAHOKIA IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/02/2010	a two-hour-resistant firewall in common walls.	Widespread	Minimal harm or potential for actual harm
06/02/2010	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
06/02/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
06/02/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
06/02/2010	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
06/02/2010	emergency lighting that can last at least 1 1/2 hours.	Pattern	Minimal harm or potential for actual harm
06/02/2010	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
06/02/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
06/02/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
06/02/2010	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
06/02/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
06/02/2010	have an adequate water supply for the sprinkler system.	Pattern	Minimal harm or potential for actual harm
06/02/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Pattern	Minimal harm or potential for actual harm
06/02/2010	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
06/02/2010	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
06/02/2010	no-smoking signs where oxygen is used.	Pattern	Minimal harm or potential for actual harm
06/02/2010	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Minimal harm or potential for actual harm
06/02/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
06/02/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
06/02/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
05/04/2010	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
05/04/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
05/04/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
05/04/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
05/04/2010	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
05/04/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
05/04/2010	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
03/24/2009	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.	Isolated	Minimal harm or potential for actual harm
03/24/2009	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Minimal harm or potential for actual harm
03/24/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
03/24/2009	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
03/24/2009	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
03/24/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
03/24/2009	Offer other nutritional food to each resident who will not eat the food served.	Isolated	Minimal harm or potential for actual harm
03/24/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
03/24/2009	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
03/24/2009	Get services outside the nursing home that meet professional standards.	Isolated	Minimal harm or potential for actual harm
03/24/2009	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
04/11/2008	Listen to the resident or family groups or act on their complaints or suggestions.	Pattern	Potential for minimal harm
04/11/2008	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
04/11/2008	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.	Isolated	Minimal harm or potential for actual harm
04/11/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
04/11/2008	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
04/11/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
04/11/2008	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
04/10/2008	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm

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Where does this data come from?

The data on this website describes nursing home characteristics, quality measures, inspection results, and nursing staff information.

The data come from 2 sources:

1. Centers for Medicare & Medicaid Services (CMS) have an Online Survey, Certification, and Reporting (OSCAR) database - Includes the nursing home characteristics and health deficiencies issued during the three most recent state inspections and recent complaint investigations.

   The survey inspection results are collected by the state survey agencies, who perform onsite visits to nursing homes . The inspections occur at least once during a 15-month period, or any time in between as a result of a complaint received by the state. The inspections ensure that the nursing home residents receive quality care and services in a safe and comfortable environment in accordance with rules established by CMS. Complaints may be reported and inspected during the year (outside of the 9-15 month survey cycle). Inspections about a complaint that result in the citation of a health deficiency are reported to CMS and included in this website. Sometimes the inspection finds a problem that the nursing home identified and corrected before the inspection occurred. The fact and the nature of these prior problems (deficiencies) may be included in this website.

   The information on the nursing homes' characteristics derived from OSCAR are prepared by each nursing home at the beginning of the regular State inspection. This information is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure data accuracy. In addition, this information changes frequently as residents are discharged and admitted, or resident conditions change.

2. National database known as the Minimum Data Set (MDS) Repository

   The data for the quality measures come from the MDS Repository. The MDS is collected on regular intervals for every resident in a Medicare or Medicaid certified nursing home. Information is collected on the resident's health, physical functioning, mental status, and general well-being. These data are used by the nursing home to access the needs and develop a plan of care unique to each resident.

   Regulations require that a MDS assessment be performed at admission, quarterly, annually, and whenever the resident experiences a significant change in status. For residents in a Medicare Part A stay, the MDS is also used to determine the Medicare reimbursement rate. These assessments are performed on the 5th, 14th, 30th, 60th and 90th day of admission.

   All of this data is reported by the nursing homes themselves. It is reviewed by nursing home inspectors, but not formally audited to ensure that it is accurate. Every attempt is made to assure the accuracy and timeliness of this information. However, this information changes frequently as residents are discharged and admitted, or resident conditions change. We advise interpreting this information cautiously and supplementing it with information from the Ombudsman's office, the State Survey Agency, or other sources.

   Some MDS items used to calculate the quality measures consider the resident's condition during previous days prior to the assessment date. The following table provides these "observation" or "look back" time frames.

Signs of Nursing Home Abuse:

• Unexplained injuries or bruises
• Over or under medication
• Visible cuts, bruises, or welts
• Rapid weight loss or weight gain
• Dehydration, malnutrition, and bedsores
• Unsanitary living conditions
• Infections
• Broken bones
• Sudden death