GLENSHIRE NURSING & REHAB CTRE IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/04/2010	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
02/19/2010	Let the appropriate people see and talk to each resident.	Widespread	Potential for minimal harm
02/19/2010	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
02/19/2010	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
02/19/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
02/19/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
02/19/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
02/19/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
02/19/2010	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
02/19/2010	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
02/19/2010	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
02/19/2010	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
02/19/2010	Give or get special rehabilitation if in the patient's plan of care.	Pattern	Minimal harm or potential for actual harm
02/19/2010	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
02/19/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
02/19/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
02/19/2010	Keep all essential equipment working safely.	Isolated	Minimal harm or potential for actual harm
02/05/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
02/05/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
01/20/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
01/20/2009	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
01/20/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
01/20/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
01/20/2009	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
01/20/2009	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
01/20/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Potential for minimal harm
01/11/2008	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
01/11/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
01/11/2008	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
01/11/2008	restrictions on the use of portable space heaters.	Pattern	Minimal harm or potential for actual harm
01/11/2008	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
01/11/2008	an elevator that firefighters can control in the event of a fire.	Pattern	Minimal harm or potential for actual harm
12/20/2007	Keep safe, clean and homelike surroundings.	Pattern	Potential for minimal harm
12/20/2007	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
12/20/2007	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
12/20/2007	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/20/2007	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
12/20/2007	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	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