OTTAWA PAVILION IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
02/19/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
02/18/2010	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
02/18/2010	an automatic smoke detection system in all hallways.	Widespread	Minimal harm or potential for actual harm
05/27/2009	smoke barrier doors that can resist smoke for at least 20 minutes.	Pattern	Minimal harm or potential for actual harm
05/27/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
05/27/2009	protected exits that allow the resident to escape the building.	Pattern	Minimal harm or potential for actual harm
05/27/2009	exits that are accessible at all times.	Pattern	Minimal harm or potential for actual harm
05/27/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
05/27/2009	an automatic smoke detection system in all hallways.	Pattern	Minimal harm or potential for actual harm
05/27/2009	an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Minimal harm or potential for actual harm
05/27/2009	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
05/27/2009	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
05/27/2009	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
05/27/2009	automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
04/30/2009	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.	Isolated	Minimal harm or potential for actual harm
04/30/2009	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
04/30/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
04/30/2009	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
04/30/2009	Have enough backup water supply for important areas of the nursing home.	Widespread	Minimal harm or potential for actual harm
03/31/2008	Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Widespread	Potential for minimal harm
03/31/2008	Provide enough notice before discharging or transferring a resident.	Isolated	Minimal harm or potential for actual harm
03/31/2008	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
03/31/2008	Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
03/31/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
03/31/2008	Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
03/31/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
03/31/2008	Keep all essential equipment working safely.	Pattern	Minimal harm or potential for actual harm
03/26/2008	fire-resistant interior walls.	Pattern	Minimal harm or potential for actual harm
03/26/2008	fire-resistant room wall surfaces.	Pattern	Minimal harm or potential for actual harm
03/26/2008	exit stairways and towers that are smoke proof.	Pattern	Minimal harm or potential for actual harm
03/26/2008	proper backup exit lighting.	Widespread	Minimal harm or potential for actual harm
03/26/2008	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
03/26/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
03/26/2008	have an adequate water supply for the sprinkler system.	Widespread	Minimal harm or potential for actual harm
03/26/2008	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
03/26/2008	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
03/26/2008	properly sized and located linen or trash receptacles.	Pattern	Minimal harm or potential for actual harm
03/26/2008	weekly inspections and monthly testing of generators.	Widespread	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