SHERIDAN SHORES CR & REHAB CTR IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
07/08/2010	proper stairway enclosures and vertical shafts.	Widespread	Minimal harm or potential for actual harm
07/08/2010	an approved installation, maintenance and testing program for fire alarm systems.	Widespread	Minimal harm or potential for actual harm
07/08/2010	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
07/08/2010	proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm
06/24/2010	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal 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.	Pattern	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	Keep assessments completed in the preceding 15 months in the resident's active record.	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	Minimal harm or potential for actual harm
06/24/2010	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
06/24/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
06/24/2010	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
06/24/2010	Make sure that residents are well nourished.	Isolated	Minimal harm or potential for actual harm
06/24/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for 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
06/24/2010	Have enough backup water supply for important areas of the nursing home.	Widespread	Potential for minimal harm
05/07/2009	properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
05/07/2009	properly working alarms on sprinkler valves.	Widespread	Minimal harm or potential for actual harm
05/07/2009	proper fire barriers, ventilation and signs for the transport of oxygen.	Widespread	Minimal harm or potential for actual harm
04/23/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
04/23/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
04/23/2009	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.	Pattern	Minimal harm or potential for actual harm
04/23/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
04/23/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
04/23/2009	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
04/23/2009	Give or get special rehabilitation if in the patient's plan of care.	Pattern	Minimal harm or potential for actual harm
05/23/2008	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Widespread	Minimal harm or potential for actual harm
05/23/2008	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
05/23/2008	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
05/16/2008	Have a private telephone available for use.	Widespread	Potential for minimal harm
05/16/2008	Provide written records when a resident is transferred or discharged.	Isolated	Minimal harm or potential for actual harm
05/16/2008	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
05/16/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
05/16/2008	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
05/16/2008	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.	Pattern	Minimal harm or potential for actual harm
05/16/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
05/16/2008	Provide a final summary of the resident's health status and a summary of the resident's stay, when the resident is ready to leave the nursing home.	Isolated	Minimal harm or potential for actual harm
05/16/2008	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
05/16/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
05/16/2008	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
05/16/2008	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
05/16/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
05/16/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Isolated	Minimal harm or potential for actual harm
05/16/2008	Store, cook, and give out food in a safe and clean way.	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