MONROE PAV HLTH-TREATMENT CTR IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
07/30/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
07/30/2010	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
07/30/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
07/29/2010	Protect each resident from all abuse, physical punishment, and being separated from others.	Isolated	Immediate jeopardy to resident health or safety
07/29/2010	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
07/29/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
07/29/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
07/29/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Immediate jeopardy to resident health or safety
07/29/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
07/29/2010	Give or get special rehabilitation if in the patient's plan of care.	Widespread	Minimal harm or potential for actual harm
07/29/2010	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
10/09/2009	posted "No-smoking" signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Widespread	Minimal harm or potential for actual harm
09/25/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
09/25/2009	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
09/25/2009	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
09/25/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
09/25/2009	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
09/25/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
09/25/2009	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
09/25/2009	Have enough backup water supply for important areas of the nursing home.	Widespread	Potential for minimal harm
09/25/2009	Keep clinical information safe, so that it will not be lost, destroyed or used by the wrong person.	Pattern	Minimal harm or potential for actual harm
08/29/2008	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
08/29/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
08/29/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
08/29/2008	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
08/29/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
08/26/2008	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
08/26/2008	Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm
08/26/2008	Give enough notice to the resident before changing the resident's room or roommate.	Isolated	Minimal harm or potential for actual harm
08/26/2008	Keep safe, clean and homelike surroundings.	Pattern	Potential for minimal harm
08/26/2008	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
08/26/2008	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
08/26/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
08/26/2008	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
08/26/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
08/26/2008	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
08/26/2008	Give or get special rehabilitation if in the patient's plan of care.	Pattern	Minimal harm or potential for actual harm
08/26/2008	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
08/26/2008	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
08/26/2008	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Pattern	Potential for minimal harm
08/26/2008	Follow all laws and professional standards.	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