FONDULAC REHABILITATION & HCC IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
08/03/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
08/03/2010	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
08/03/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
08/03/2010	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
08/03/2010	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
08/03/2010	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
08/03/2010	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
08/03/2010	proper fire barriers, ventilation and signs for the transport of oxygen.	Widespread	Minimal harm or potential for actual harm
08/03/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
08/03/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
07/16/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
07/16/2010	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
08/14/2009	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
08/14/2009	approved construction type or materials.	Pattern	Minimal harm or potential for actual harm
08/14/2009	fire-resistant interior walls.	Pattern	Minimal harm or potential for actual harm
08/14/2009	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
08/14/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
08/14/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
08/14/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
08/14/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
08/14/2009	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
08/14/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
08/14/2009	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
08/14/2009	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
08/14/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
08/14/2009	have an adequate water supply for the sprinkler system.	Widespread	Minimal harm or potential for actual harm
08/14/2009	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
08/14/2009	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Minimal harm or potential for actual harm
08/14/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
08/14/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
08/14/2009	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
06/25/2009	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.	Pattern	Minimal harm or potential for actual harm
06/25/2009	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Minimal harm or potential for actual harm
06/25/2009	Keep safe, clean and homelike surroundings.	Pattern	Potential for minimal harm
06/25/2009	Provide needed housekeeping and maintenance.	Isolated	Minimal harm or potential for actual harm
06/25/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
06/25/2009	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
06/25/2009	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
06/25/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
06/25/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
06/25/2009	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
06/25/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
06/25/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
06/25/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
06/25/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
06/25/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
06/25/2009	Train all employees on what to do in an emergency.	Pattern	Minimal harm or potential for actual harm
07/16/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
07/16/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
07/16/2008	Get proof that a nurse aide has the training and skills that the State requires.	Widespread	Potential for minimal harm
07/14/2008	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
07/14/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
07/14/2008	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
07/14/2008	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
07/14/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
07/14/2008	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
07/14/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
07/14/2008	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
07/14/2008	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	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