WATERFRONT TERRACE IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
04/08/2010	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Widespread	Minimal harm or potential for actual harm
04/08/2010	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
04/08/2010	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
04/08/2010	record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
04/08/2010	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
04/08/2010	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
04/08/2010	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
04/08/2010	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
02/10/2010	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
02/10/2010	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
02/10/2010	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
02/10/2010	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
02/10/2010	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
02/10/2010	Make sure that residents are safe from serious medication errors.	Pattern	Minimal harm or potential for actual harm
02/10/2010	Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
01/29/2009	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
01/29/2009	Allow residents to easily see the results of the nursing home's most recent survey.	Isolated	Minimal harm or potential for actual harm
01/29/2009	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
01/29/2009	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
01/29/2009	Keep safe, clean and homelike surroundings.	Pattern	Minimal harm or potential for actual harm
01/29/2009	Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
01/29/2009	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
01/29/2009	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
01/29/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
01/29/2009	an elevator that firefighters can control in the event of a fire.	Widespread	Minimal harm or potential for actual harm
01/29/2009	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
01/29/2009	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
01/29/2009	Get rid of garbage properly.	Isolated	Minimal harm or potential for actual harm
01/29/2009	Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Isolated	Minimal harm or potential for actual harm
01/29/2009	Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
01/29/2009	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
01/29/2009	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	Minimal harm or potential for actual harm
01/29/2009	corridor and hallway doors that block smoke.	Widespread	Minimal harm or potential for actual harm
01/29/2009	construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
01/29/2009	did not have a written emergency evacuation plan.	Widespread	Minimal harm or potential for actual harm
01/29/2009	record of quarterly fire drills for each shift under varying conditions.	Widespread	Minimal harm or potential for actual harm
01/29/2009	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
01/29/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
01/29/2009	portable fire extinguishers.	Widespread	Minimal harm or potential for actual harm
01/29/2009	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
01/29/2009	properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
01/29/2009	weekly inspections and monthly testing of generators.	Widespread	Minimal harm or potential for actual harm
01/29/2009	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
02/11/2008	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
02/11/2008	Provide activities to meet the needs of each resident.	Isolated	Minimal harm or potential for actual harm
02/11/2008	Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
02/11/2008	Make sure that residents are safe from serious medication errors.	Isolated	Minimal harm or potential for actual harm
02/11/2008	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