MOWEAQUA NRSG & RETIREMENT CTR IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/19/2011	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
01/19/2011	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
01/19/2011	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
01/19/2011	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
01/19/2011	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
10/22/2010	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
10/22/2010	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
10/22/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
10/22/2010	Make sure that the attending doctor orders special diets.	Isolated	Minimal harm or potential for actual harm
10/22/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/03/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
02/03/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
02/03/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
02/03/2010	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
02/03/2010	an externally vented heating system.	Pattern	Minimal harm or potential for actual harm
02/03/2010	proper medical gas storage and administration areas.	Pattern	Minimal harm or potential for actual harm
02/03/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
02/03/2010	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
02/03/2010	properly installed hallway dispensers for alcohol-based hand rub.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Bill properly: Charged resident for items that Medicare or Medicaid pays for.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Develop/implement required procedures for the administration of immunizations.	Isolated	Minimal harm or potential for actual harm
12/23/2009	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
12/23/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
12/23/2009	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Widespread	Minimal harm or potential for actual harm
12/23/2009	Make sure there is a program to prevent/deal with mice, insects, or other pests.	Isolated	Minimal harm or potential for actual harm
03/18/2009	a two-hour-resistant firewall in common walls.	Pattern	Minimal harm or potential for actual harm
03/18/2009	fire-resistant interior walls.	Widespread	Minimal harm or potential for actual harm
03/18/2009	fire-resistant room wall surfaces.	Widespread	Minimal harm or potential for actual harm
03/18/2009	corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
03/18/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
03/18/2009	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
03/18/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
03/18/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
03/18/2009	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
03/18/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
03/18/2009	proper facilities for the use and storage of combustible liquids.	Isolated	Minimal harm or potential for actual harm
03/18/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
03/18/2009	properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
01/09/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
01/09/2009	Hire a qualified dietician.	Widespread	Minimal harm or potential for actual harm
01/09/2009	Make sure that residents are well nourished.	Pattern	Minimal harm or potential for actual harm
01/09/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
01/09/2009	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
01/09/2009	Store, cook, and give out food in a safe and clean way.	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