ELMWOOD CARE IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/10/2010	Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help.	Widespread	Potential for minimal harm
02/10/2010	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
02/10/2010	Provide clean bed and bath linens that are in good condition.	Pattern	Minimal harm or potential for actual harm
02/10/2010	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
02/10/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
02/10/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
02/10/2010	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
02/10/2010	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
02/10/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
02/10/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
02/10/2010	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
12/18/2008	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
12/18/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/18/2008	proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm
12/18/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
12/18/2008	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Immediate jeopardy to resident health or safety
12/16/2008	Keep each resident free from drugs that restrain them, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Protect residents from mistreatment, neglect, and/or theft of personal property.	Pattern	Immediate jeopardy to resident health or safety
12/16/2008	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.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Provide needed housekeeping and maintenance.	Widespread	Minimal harm or potential for actual harm
12/16/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Widespread	Minimal harm or potential for actual harm
12/16/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
12/16/2008	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Pattern	Immediate jeopardy to resident health or safety
12/16/2008	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Immediate jeopardy to resident health or safety
12/16/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Actual harm
12/16/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Immediate jeopardy to resident health or safety
12/16/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Give or get special rehabilitation if in the patient's plan of care.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Provide enough emergency electricity.	Pattern	Minimal harm or potential for actual harm
12/16/2008	Provide bedrooms that don't allow residents to see each other when privacy is needed.	Isolated	Minimal harm or potential for actual harm
12/16/2008	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Immediate jeopardy to resident health or safety
12/16/2008	Make sure that nurse aides show they have the skills to be able to care for residents.	Widespread	Minimal harm or potential for actual harm
12/16/2008	Set up or keep a group of people to review and ensure quality.	Widespread	Immediate jeopardy to resident health or safety
01/17/2008	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
01/17/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
01/17/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
01/17/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
01/17/2008	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Minimal harm or potential for actual harm
01/17/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
01/17/2008	proper backup exit lighting.	Widespread	Minimal harm or potential for actual harm
01/17/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
01/17/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
01/17/2008	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
01/17/2008	an elevator that firefighters can control in the event of a fire.	Pattern	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