HOPE CREEK CARE CENTER IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
08/18/2010	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Immediate jeopardy to resident health or safety
08/18/2010	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	Immediate jeopardy to resident health or safety
08/18/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Actual harm
08/18/2010	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
08/18/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
08/18/2010	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
08/18/2010	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
08/09/2010	properly located and lighted "Exit" signs.	Pattern	Minimal harm or potential for actual harm
08/09/2010	a fire alarm system that can be heard throughout the facility.	Isolated	Minimal harm or potential for actual harm
07/30/2009	Let the resident refuse treatment or refuse to take part in an experiment.	Isolated	Minimal harm or potential for actual harm
07/30/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
07/30/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
07/30/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
07/30/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
07/30/2009	Get proof that a nurse aide has the training and skills that the State requires.	Widespread	Potential for minimal harm
06/26/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
06/26/2008	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
06/26/2008	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
06/26/2008	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
06/26/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
06/26/2008	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
06/26/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
06/24/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
06/24/2008	properly constructed windows in hallway walls or doors.	Pattern	Minimal harm or potential for actual harm
06/24/2008	protected exits that allow the resident to escape the building.	Pattern	Minimal harm or potential for actual harm
06/24/2008	exit stairways and towers that are smoke proof.	Widespread	Minimal harm or potential for actual harm
06/24/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
06/24/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
06/24/2008	portable fire extinguishers.	Pattern	Minimal harm or potential for actual harm
06/24/2008	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
06/24/2008	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
06/24/2008	properly installed electrical wiring and equipment.	Isolated	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