LAKE SHORE HLTHCARE &REHAB CTR IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
11/18/2010	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
11/18/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Widespread	Minimal harm or potential for actual harm
11/18/2010	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
11/18/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
11/18/2010	proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Minimal harm or potential for actual harm
10/28/2010	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
10/28/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
10/28/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
10/28/2010	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
10/28/2010	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
10/28/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/28/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
10/28/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/02/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
12/02/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
12/02/2009	proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm
11/20/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
11/20/2009	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
11/20/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
11/20/2009	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
11/20/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
11/20/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
11/20/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
12/31/2008	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
12/31/2008	automatic sprinkler systems that have been maintained in working order.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Make sure that private space is available in the nursing home for resident groups or residents' families to meet.	Widespread	Potential for minimal harm
12/18/2008	Listen to the resident or family groups or act on their complaints or suggestions.	Widespread	Potential for minimal harm
12/18/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
12/18/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Hire a qualified dietician.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Offer other nutritional food to each resident who will not eat the food served.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Provide special eating equipment and utensils for each resident who needs them.	Isolated	Minimal harm or potential for actual harm
12/18/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/18/2008	Give or get special rehabilitation if in the patient's plan of care.	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