CEDAR POINTE REHAB & NURSING IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
09/15/2010	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
09/15/2010	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm
08/26/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
08/26/2010	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
08/26/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
08/26/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
08/26/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
08/26/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
08/26/2010	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
08/26/2010	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
10/21/2009	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
10/21/2009	protected exits that allow the resident to escape the building.	Widespread	Minimal harm or potential for actual harm
09/17/2009	Keep each resident free from drugs that restrain them, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
09/17/2009	Protect each resident from all abuse, physical punishment, and being separated from others.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
09/17/2009	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
09/17/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Give or get special rehabilitation if in the patient's plan of care.	Pattern	Minimal harm or potential for actual harm
09/17/2009	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Isolated	Minimal harm or potential for actual harm
09/17/2009	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Widespread	Minimal harm or potential for actual harm
09/03/2008	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
09/03/2008	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
09/03/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
09/03/2008	protected exits that allow the resident to escape the building.	Widespread	Minimal harm or potential for actual harm
09/03/2008	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
09/03/2008	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
09/03/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
09/03/2008	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
09/03/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
09/03/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm
09/03/2008	exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
09/03/2008	properly sized and located linen or trash receptacles.	Widespread	Minimal harm or potential for actual harm
09/03/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
08/26/2008	Tell the resident completely about his or her health status.	Pattern	Minimal harm or potential for actual harm
08/26/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
08/26/2008	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
08/26/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
08/26/2008	Make sure that a resident does not become withdrawn, angry or depressed if these problems did not exist before.	Isolated	Minimal harm or potential for actual harm
08/26/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
08/26/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	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