RAINBOW BEACH CARE CENTER IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
07/29/2010	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
07/29/2010	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
07/29/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
07/29/2010	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
06/24/2010	Honor all of the resident's rights as a resident of the nursing home and as a citizen or resident of the United States.	Isolated	Minimal harm or potential for actual harm
06/24/2010	Provide services to meet the needs and preferences of each resident.	Widespread	Potential for minimal harm
06/24/2010	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
06/24/2010	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
06/24/2010	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
06/24/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
06/24/2010	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
06/24/2010	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
07/30/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Widespread	Minimal harm or potential for actual harm
07/30/2009	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
07/30/2009	protected exits that allow the resident to escape the building.	Widespread	Minimal harm or potential for actual harm
07/30/2009	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
07/30/2009	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
07/30/2009	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
07/30/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
07/30/2009	have an adequate water supply for the sprinkler system.	Widespread	Minimal harm or potential for actual harm
07/30/2009	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
07/30/2009	exits that are free from obstructions and can be used at all times.	Widespread	Minimal harm or potential for actual harm
07/30/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
07/30/2009	an elevator that firefighters can control in the event of a fire.	Widespread	Minimal harm or potential for actual harm
07/16/2009	Provide enough notice before discharging or transferring a resident.	Isolated	Minimal harm or potential for actual harm
07/16/2009	Provide needed housekeeping and maintenance.	Pattern	Potential for minimal harm
07/16/2009	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Pattern	Minimal harm or potential for actual harm
07/16/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
07/16/2009	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
07/16/2009	Hire a qualified dietician.	Pattern	Minimal harm or potential for actual harm
07/16/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
07/16/2009	Get rid of garbage properly.	Pattern	Potential for minimal harm
07/16/2009	Provide at least one room to use as a dining room and for activities, that is a good size, with good lighting, airflow and furniture.	Pattern	Potential for minimal harm
05/28/2008	Tell the resident completely about his or her health status.	Isolated	Minimal harm or potential for actual harm
05/28/2008	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	Immediate jeopardy to resident health or safety
05/28/2008	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Immediate jeopardy to resident health or safety
05/28/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Isolated	Minimal harm or potential for actual harm
05/28/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
05/28/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
05/28/2008	Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Actual harm
05/28/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Immediate jeopardy to resident health or safety
05/28/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
05/28/2008	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
05/23/2008	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
05/23/2008	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
05/23/2008	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Minimal harm or potential for actual harm
05/23/2008	smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
05/23/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
05/23/2008	proper construction of ducts through walls designed to prevent smoke passage.	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