ST AGNES HC AND REHAB CENTER IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/02/2010	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
06/02/2010	an approved automatic sprinkler system connected to the fire alarm system.	Widespread	Minimal harm or potential for actual harm
06/02/2010	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
06/02/2010	protected exits that allow the resident to escape the building.	Widespread	Minimal harm or potential for actual harm
06/02/2010	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
06/02/2010	heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Minimal harm or potential for actual harm
06/02/2010	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
06/02/2010	proper fire barriers, ventilation and signs for the transport of oxygen.	Widespread	Minimal harm or potential for actual harm
03/18/2010	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
03/18/2010	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
03/18/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
03/18/2010	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
03/18/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
02/20/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
02/20/2009	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
02/20/2009	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
02/20/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
02/20/2009	Have a program to keep infection from spreading.	Widespread	Potential for minimal harm
02/20/2009	Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Potential for minimal harm
02/20/2009	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
02/20/2009	proper stairway enclosures and vertical shafts.	Widespread	Minimal harm or potential for actual harm
02/20/2009	protected exits that allow the resident to escape the building.	Widespread	Minimal harm or potential for actual harm
02/20/2009	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
02/20/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
02/20/2009	have an adequate water supply for the sprinkler system.	Pattern	Minimal harm or potential for actual harm
02/20/2009	proper construction of ducts through walls designed to prevent smoke passage.	Widespread	Minimal harm or potential for actual harm
02/20/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
04/18/2008	Make sure that each resident's nutritional needs were met.	Isolated	Actual harm
04/18/2008	Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.	Isolated	Immediate jeopardy to resident health or safety
04/18/2008	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Make sure that residents are safe from serious medication errors.	Isolated	Actual harm
04/18/2008	Develop/implement required procedures for the administration of immunizations.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Widespread	Minimal harm or potential for actual harm
04/18/2008	post nurse staffing information.	Widespread	Potential for minimal harm
04/18/2008	Make sure that residents are well nourished.	Widespread	Potential for minimal harm
04/18/2008	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Potential for minimal harm
04/18/2008	Make sure that the attending doctor orders special diets.	Widespread	Minimal harm or potential for actual harm
04/18/2008	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
04/18/2008	Get rid of garbage properly.	Pattern	Potential for minimal harm
04/18/2008	Give or get special rehabilitation if in the patient's plan of care.	Isolated	Minimal harm or potential for actual harm
04/18/2008	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
04/18/2008	Have a program to keep infection from spreading.	Isolated	Immediate jeopardy to resident health or safety
04/18/2008	Keep all essential equipment working safely.	Isolated	Actual harm
04/18/2008	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
04/18/2008	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
04/18/2008	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Make sure that nurse aides show they have the skills to be able to care for residents.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Have licensed, certified, or registered staff to give needed services.	Isolated	Minimal harm or potential for actual harm
04/18/2008	Choose a doctor to be the medical director.	Widespread	Minimal harm or potential for actual harm
04/18/2008	Quickly tell the resident's doctor the results of lab tests.	Pattern	Actual harm
04/18/2008	Set up or keep a group of people to review and ensure quality.	Widespread	Minimal harm or potential for actual harm
04/18/2008	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Provide needed housekeeping and maintenance.	Widespread	Potential for minimal harm
04/18/2008	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
04/18/2008	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Pattern	Minimal harm or potential for actual harm
04/18/2008	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
04/18/2008	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Immediate jeopardy to resident health or safety
04/18/2008	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Actual harm
04/18/2008	Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
04/18/2008	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Widespread	Minimal harm or potential for actual harm
04/18/2008	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	Actual harm
04/18/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Actual harm
04/18/2008	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
04/18/2008	Let each resident choose whether to manage his or her own money or deposit it with the nursing home.	Isolated	Minimal harm or potential for actual harm
04/18/2008	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
04/18/2008	Have a private telephone available for use.	Widespread	Potential for minimal harm
04/18/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
04/18/2008	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Actual harm
04/18/2008	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.	Widespread	Minimal harm or potential for actual harm
04/18/2008	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
04/18/2008	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
04/18/2008	Hire a qualified activities director.	Pattern	Minimal harm or potential for actual harm
03/18/2008	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
03/18/2008	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
03/18/2008	properly protected cooking facilities.	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