FOX RIVER PAVILION IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/11/2009	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
12/11/2009	a two-hour-resistant firewall in common walls.	Widespread	Minimal harm or potential for actual harm
12/11/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/11/2009	properly constructed windows in hallway walls or doors.	Pattern	Minimal harm or potential for actual harm
12/11/2009	proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm
12/11/2009	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
12/11/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
12/11/2009	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
12/11/2009	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
12/11/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
12/11/2009	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
12/11/2009	an automatic smoke detection system in all hallways.	Isolated	Minimal harm or potential for actual harm
12/11/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
12/11/2009	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Minimal harm or potential for actual harm
12/11/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
12/11/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
12/11/2009	an elevator that firefighters can control in the event of a fire.	Widespread	Minimal harm or potential for actual harm
11/04/2009	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Actual harm
11/04/2009	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Immediate jeopardy to resident health or safety
11/04/2009	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.	Isolated	Minimal harm or potential for actual harm
11/04/2009	Keep safe, clean and homelike surroundings.	Isolated	Minimal harm or potential for actual harm
11/04/2009	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
11/04/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/04/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Immediate jeopardy to resident health or safety
11/04/2009	Develop/implement required procedures for the administration of immunizations.	Widespread	Minimal harm or potential for actual harm
11/04/2009	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Actual harm
11/04/2009	Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) an adequate bed; 4) furniture that meets the resident's needs; or 5) enough closet space.	Isolated	Minimal harm or potential for actual harm
01/23/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
01/23/2009	exit stairways and towers that are smoke proof.	Pattern	Minimal harm or potential for actual harm
01/23/2009	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
01/23/2009	proper fire barriers, ventilation and signs for the transport of oxygen.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Check and update (if needed) each resident's assessment every 3 months.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Keep assessments completed in the preceding 15 months in the resident's active record.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
12/15/2008	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
12/15/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
12/15/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Actual harm
12/15/2008	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
12/15/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Immediate jeopardy to resident health or safety
12/15/2008	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
12/15/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
12/15/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
12/15/2008	post nurse staffing information.	Widespread	Potential for minimal harm
12/15/2008	Hire a qualified dietician.	Widespread	Minimal harm or potential for actual harm
12/15/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
12/15/2008	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Widespread	Potential for minimal harm
12/15/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/15/2008	Get rid of garbage properly.	Widespread	Potential for minimal harm
12/15/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
12/15/2008	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
12/15/2008	Hire nurse aides who have shown that they are skilled and care for residents safely on-the-job.	Isolated	Minimal harm or potential for actual harm
12/15/2008	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
12/15/2008	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
12/15/2008	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.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
12/15/2008	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Keep temperature levels comfortable and safe.	Pattern	Minimal harm or potential for actual harm
12/15/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
11/28/2007	Provide enough notice before discharging or transferring a resident.	Isolated	Minimal harm or potential for actual harm
11/28/2007	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
11/28/2007	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
11/28/2007	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
11/28/2007	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
11/28/2007	Keep temperature levels comfortable and safe.	Pattern	Minimal harm or potential for actual harm
11/28/2007	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
11/28/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
11/28/2007	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
11/28/2007	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
11/28/2007	Give or get special rehabilitation if in the patient's plan of care.	Pattern	Minimal harm or potential for actual harm
11/28/2007	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
11/27/2007	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
11/27/2007	a two-hour-resistant firewall in common walls.	Widespread	Minimal harm or potential for actual harm
11/27/2007	fire-resistant interior walls.	Pattern	Minimal harm or potential for actual harm
11/27/2007	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
11/27/2007	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
11/27/2007	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
11/27/2007	properly constructed windows in hallway walls or doors.	Pattern	Minimal harm or potential for actual harm
11/27/2007	proper stairway enclosures and vertical shafts.	Widespread	Minimal harm or potential for actual harm
11/27/2007	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
11/27/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
11/27/2007	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
11/27/2007	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
11/27/2007	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
11/27/2007	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
11/27/2007	restrictions on the use of portable space heaters.	Pattern	Minimal harm or potential for actual harm
11/27/2007	restrictions on the use of flammable curtains.	Widespread	Minimal harm or potential for actual harm
11/27/2007	properly sized and located linen or trash receptacles.	Pattern	Minimal harm or potential for actual harm
11/27/2007	proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
11/27/2007	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
11/27/2007	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
11/27/2007	an approved back-up procedure for a faulty fire alarm system.	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