LAKE COUNTY NURSING & REHABILITATION CENTER IN DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
12/02/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
12/02/2009	exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Pattern	Minimal harm or potential for actual harm
12/02/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
12/02/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
12/02/2009	fire safety features required by current fire safety codes.	Widespread	Minimal harm or potential for actual harm
12/02/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
12/02/2009	properly installed hallway dispensers for alcohol-based hand rub.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Pattern	Minimal harm or potential for actual harm
11/25/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Pattern	Potential for minimal harm
11/25/2009	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Have a private telephone available for use.	Pattern	Potential for minimal harm
11/25/2009	Keep each resident free from drugs that restrain them, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
11/25/2009	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
11/25/2009	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
11/25/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Pattern	Potential for minimal harm
11/25/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
11/25/2009	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
11/25/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
11/25/2009	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
11/25/2009	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
11/25/2009	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
11/25/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
11/25/2009	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
11/25/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Immediate jeopardy to resident health or safety
11/25/2009	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Pattern	Minimal harm or potential for actual harm
11/25/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
11/25/2009	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.	Pattern	Minimal harm or potential for actual harm
11/25/2009	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
11/25/2009	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
11/25/2009	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
11/25/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Be administered in a way that leads to the highest possible level of well being for each resident.	Pattern	Immediate jeopardy to resident health or safety
11/25/2009	Hire nurse aides who have completed required training and shown that they are skilled.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Have licensed, certified, or registered staff to give needed services.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Give or get x-rays or tests only when the resident's doctor ordered them.	Isolated	Minimal harm or potential for actual harm
11/25/2009	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
11/25/2009	Train all employees on what to do in an emergency.	Isolated	Minimal harm or potential for actual harm
11/06/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Widespread	Minimal harm or potential for actual harm
11/06/2008	fire-resistant interior walls.	Widespread	Minimal harm or potential for actual harm
11/06/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
11/06/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
11/06/2008	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
11/06/2008	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
11/06/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
10/14/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Keep safe, clean and homelike surroundings.	Pattern	Potential for minimal harm
10/14/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
10/14/2008	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
10/14/2008	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
10/14/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
10/14/2008	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
10/14/2008	post nurse staffing information.	Pattern	Potential for minimal harm
10/14/2008	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Make sure that a doctor approves a resident's admission in writing and that each resident has a doctor.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Potential for minimal harm
10/14/2008	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
10/14/2008	Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
10/14/2008	Keep accurate and appropriate medical records.	Pattern	Minimal harm or potential for actual harm
07/17/2007	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
07/17/2007	signs that state that exit doors are to be kept closed.	Pattern	Minimal harm or potential for actual harm
07/17/2007	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
07/17/2007	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
07/17/2007	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
07/17/2007	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
07/17/2007	an approved installation, maintenance and testing program for fire alarm systems.	Pattern	Minimal harm or potential for actual harm
07/17/2007	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
07/17/2007	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
07/17/2007	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
07/17/2007	fire safety features required by current fire safety codes.	Pattern	Minimal harm or potential for actual harm
07/17/2007	properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
07/13/2007	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
07/13/2007	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
07/13/2007	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
07/13/2007	Store, cook, and give out food in a safe and clean way.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
07/13/2007	Quickly tell the resident's doctor the results of lab tests.	Isolated	Minimal harm or potential for actual harm
07/13/2007	Keep accurate and appropriate medical records.	Isolated	Minimal harm or potential for actual harm

Have you or someone you know become a victim of nursing home abuse or neglect? If so, contact one of our experienced nursing home lawyers today. Help End Nursing Home Abuse

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