HELIA HEALTHCARE OF ZION IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
07/09/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
07/09/2009	Keep each resident free from drugs that restrain them, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
07/09/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
07/09/2009	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
07/09/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
07/09/2009	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
07/09/2009	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.	Isolated	Minimal harm or potential for actual harm
07/09/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
07/09/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
07/09/2009	Make sure that residents are well nourished.	Widespread	Potential for minimal harm
07/09/2009	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
07/09/2009	Have enough backup water supply for important areas of the nursing home.	Widespread	Minimal harm or potential for actual harm
07/09/2009	1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator.	Widespread	Minimal harm or potential for actual harm
07/09/2009	Have a detailed, written plan for disasters and emergencies.	Pattern	Minimal harm or potential for actual harm
07/09/2009	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
07/09/2009	a two-hour-resistant firewall in common walls.	Widespread	Minimal harm or potential for actual harm
07/09/2009	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
07/09/2009	fire-resistant room wall surfaces.	Widespread	Minimal harm or potential for actual harm
07/09/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Widespread	Minimal harm or potential for actual harm
07/09/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
07/09/2009	properly constructed windows in hallway walls or doors.	Pattern	Minimal harm or potential for actual harm
07/09/2009	proper backup exit lighting.	Widespread	Minimal harm or potential for actual harm
07/09/2009	record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
07/09/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
07/09/2009	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
07/09/2009	fire-resistant Interior walls.	Pattern	Minimal harm or potential for actual harm
07/09/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
04/16/2008	Have a private telephone available for use.	Widespread	Potential for minimal harm
04/16/2008	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
04/16/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Widespread	Minimal harm or potential for actual harm
04/16/2008	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
04/16/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Pattern	Minimal harm or potential for actual harm
04/16/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
04/16/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
04/16/2008	Get proof that a nurse aide has the training and skills that the State requires.	Isolated	Minimal harm or potential for actual harm
04/16/2008	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Widespread	Potential for minimal harm
04/15/2008	a two-hour-resistant firewall in common walls.	Widespread	Minimal harm or potential for actual harm
04/15/2008	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
04/15/2008	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
04/15/2008	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
04/15/2008	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
04/15/2008	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
04/15/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
04/15/2008	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
04/15/2008	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
04/15/2008	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
04/15/2008	properly constructed linen or trash chutes.	Pattern	Minimal harm or potential for actual harm
04/15/2008	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
04/15/2008	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
04/15/2008	proper stairway enclosures and vertical shafts.	Pattern	Minimal harm or potential for actual harm
05/31/2007	Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Minimal harm or potential for actual harm
05/31/2007	Make sure that residents are well nourished.	Pattern	Potential for minimal harm
05/31/2007	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Potential for minimal harm
05/31/2007	Get proof that a nurse aide has the training and skills that the State requires.	Pattern	Minimal harm or potential for actual harm
05/31/2007	a two-hour-resistant firewall in common walls.	Widespread	Minimal harm or potential for actual harm
05/31/2007	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Pattern	Minimal harm or potential for actual harm
05/31/2007	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
05/31/2007	proper stairway enclosures and vertical shafts.	Widespread	Minimal harm or potential for actual harm
05/31/2007	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
05/31/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
05/31/2007	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
05/31/2007	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
05/31/2007	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
05/31/2007	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
05/31/2007	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
05/31/2007	properly constructed linen or trash chutes.	Widespread	Minimal harm or potential for actual harm
05/31/2007	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
05/31/2007	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
05/31/2007	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
05/31/2007	Make sure that the nursing home area is free of dangers that cause accidents.	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