WINCREST NURSING CENTER CORP IL DEFICIENCY REPORT

	Nursing Home Deficiency Report current as of November 25, 2009
Date	Deficiency	Scope	Level of Harm
01/05/2011	construction that can resist fire for one hour or an approved fire extinguishing system.	Widespread	Minimal harm or potential for actual harm
01/05/2011	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
01/05/2011	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
01/05/2011	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
01/05/2011	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
12/23/2010	Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Immediate jeopardy to resident health or safety
12/23/2010	Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Immediate jeopardy to resident health or safety
12/23/2010	Give or get special rehabilitation if in the patient's plan of care.	Pattern	Minimal harm or potential for actual harm
12/23/2010	Give special rehabilitation by skilled workers, when ordered by a doctor.	Pattern	Minimal harm or potential for actual harm
12/23/2010	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
12/23/2010	Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Immediate jeopardy to resident health or safety
12/22/2009	corridors that are separated from common areas by walls constructed to limit the passage of smoke.	Widespread	Minimal harm or potential for actual harm
12/22/2009	protected exits that allow the resident to escape the building.	Widespread	Minimal harm or potential for actual harm
12/22/2009	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
12/22/2009	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
12/22/2009	properly protected cooking facilities.	Widespread	Minimal harm or potential for actual harm
12/22/2009	properly sized and located linen or trash receptacles.	Widespread	Minimal harm or potential for actual harm
12/22/2009	properly installed electrical wiring and equipment.	Widespread	Minimal harm or potential for actual harm
12/22/2009	an elevator that firefighters can control in the event of a fire.	Widespread	Minimal harm or potential for actual harm
11/17/2009	Properly hold, secure and manage each resident's personal money which is deposited with the nursing home.	Isolated	Minimal harm or potential for actual harm
11/17/2009	Protect residents from mistreatment, neglect, and/or theft of personal property.	Isolated	Minimal harm or potential for actual harm
11/17/2009	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.	Isolated	Minimal harm or potential for actual harm
11/17/2009	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
11/17/2009	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
11/17/2009	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
11/17/2009	Give or get special rehabilitation if in the patient's plan of care.	Pattern	Minimal harm or potential for actual harm
11/17/2009	Give special rehabilitation by skilled workers, when ordered by a doctor.	Widespread	Minimal harm or potential for actual harm
11/17/2009	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
10/16/2008	automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
10/16/2008	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
10/16/2008	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
10/16/2008	Provide rooms that are big enough for each resident.	Pattern	Potential for minimal harm
10/16/2008	approved construction type or materials.	Widespread	Minimal harm or potential for actual harm
10/16/2008	protected exits that allow the resident to escape the building.	Widespread	Minimal harm or potential for actual harm
10/16/2008	proper backup exit lighting.	Widespread	Minimal harm or potential for actual harm
10/16/2008	a fire alarm system that can be heard throughout the facility.	Widespread	Minimal harm or potential for actual harm
10/16/2008	properly maintained smoke detectors.	Widespread	Minimal harm or potential for actual harm
10/16/2008	proper medical gas storage and administration areas.	Widespread	Minimal harm or potential for actual harm
10/16/2008	back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Minimal harm or potential for actual harm
10/16/2008	an approved back-up procedure for a faulty fire alarm system.	Widespread	Minimal harm or potential for actual harm
10/16/2008	an elevator that firefighters can control in the event of a fire.	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