STERLING PAVILION IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
06/17/2010	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
06/17/2010	walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Widespread	Minimal harm or potential for actual harm
06/17/2010	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
06/17/2010	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
06/17/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
06/17/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
06/17/2010	restrictions on the use of portable space heaters.	Widespread	Minimal harm or potential for actual harm
06/17/2010	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
06/17/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
05/22/2009	corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
05/22/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
05/22/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
05/22/2009	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
05/22/2009	proper facilities for the use and storage of combustible liquids.	Pattern	Minimal harm or potential for actual harm
05/19/2009	Keep each resident's personal and medical records private and confidential.	Pattern	Minimal harm or potential for actual harm
05/19/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
05/19/2009	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Pattern	Minimal harm or potential for actual harm
05/19/2009	Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
05/19/2009	Keep sound levels comfortable.	Widespread	Potential for minimal harm
05/19/2009	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
05/19/2009	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
05/19/2009	Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
05/19/2009	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Actual harm
05/19/2009	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
05/19/2009	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Immediate jeopardy to resident health or safety
05/19/2009	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
05/19/2009	Make sure that each resident's nutritional needs were met.	Pattern	Minimal harm or potential for actual harm
05/19/2009	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
05/19/2009	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
05/19/2009	Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Potential for minimal harm
05/19/2009	Provide food in a way that meets a resident's needs.	Pattern	Minimal harm or potential for actual harm
05/19/2009	Make sure that the attending doctor orders special diets.	Pattern	Minimal harm or potential for actual harm
05/19/2009	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Minimal harm or potential for actual harm
05/19/2009	Make sure that doctors visit residents regularly, as required.	Isolated	Minimal harm or potential for actual harm
05/19/2009	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
04/22/2008	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
04/22/2008	exits that are accessible at all times.	Widespread	Minimal harm or potential for actual harm
04/22/2008	proper backup exit lighting.	Pattern	Minimal harm or potential for actual harm
04/22/2008	emergency lighting that can last at least 1 1/2 hours.	Widespread	Minimal harm or potential for actual harm
04/22/2008	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
04/22/2008	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
04/22/2008	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
04/22/2008	exits that are free from obstructions and can be used at all times.	Pattern	Minimal harm or potential for actual harm
04/22/2008	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
04/17/2008	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
04/17/2008	Try to resolve each resident's complaints quickly.	Isolated	Minimal harm or potential for actual harm
04/17/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
04/17/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
04/17/2008	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
04/17/2008	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
04/17/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
04/17/2008	1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Pattern	Potential for minimal harm
04/17/2008	Make sure that nurse aides show they have the skills to be able to care for residents.	Isolated	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