DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 000 INITIAL COMMENTS Complaint #1212698 / IL58899 F225, F226, F354, F431 Complaint #1212719 / IL58927 - no deficiencies A Partial Extended Survey was conducted. F 225 483.13(c)(1)(ii)-(iii), (c)(2) - (4) SS=F INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

F 000

F 225

TITLE

(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 1 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 225 Continued From page 1 to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

F 225

This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure that employees do not have disqualifying convictions of battery and theft, making them ineligible to be employed in long term care. This has the potential to affect all 59 residents living in the facility. The findings include: The Facility Data Sheet of 8/9/2012 shows 59 residents reside in the facility. On 8/9/2012 at 11:00 AM, E1 (Administrator) said on 7/27/2012, she reviewed the background checks for all employees working in the facility. E1 said 2 of the nurses were found to have disqualifying convictions, making them unable to work in long term care. E2 (Registered Nurse) has a 3/29/2010 conviction for Domestic Abuse/Assault. According to the Iowa Direct Care Worker Search (8/9/2012), E2 is ineligible to be a Certified Nursing Assistant. E5 (Licensed Practical Nurse) has a 1978 conviction for theft. E1 said she suspended E2 on 7/30/2012. E1 said Z1 (Corporate Registered Nurse) told her
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 2 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 225 Continued From page 2 she had to remove the suspension because E2 holds a valid nursing license. E2 returned to work on 7/31/2012. E1 said she was going to terminate E5 also, but Z1 said she could not terminate her because she held a valid nursing license. The facility's Health Care Worker Background Check Policy and Procedure (2/28/12) states, "Any persons convicted of committing, or attempting to commit, any crime listed in the Health Care Worker Background Check Act will be immediately terminated from conditional employment/employment.. F 226 483.13(c) DEVELOP/IMPLMENT SS=F ABUSE/NEGLECT, ETC POLICIES The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

F 225

F 226

This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to follow their Abuse Policy and Procedure and their Health Care Worker Background Check Policy and Procedure by employing 2 staff members with convictions of theft and battery. This has the potential to affect all 59 residents living in the facility. The findings include: The Facility Data Sheet of 8/9/2012 shows 59
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 3 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 226 Continued From page 3 residents reside in the facility. On 8/8/2012 at 11:00 AM, E1 (Administrator) said she had 2 employees with convictions. E2 (Registered Nurse) has a 3/29/2010 conviction for Domestic Abuse/Assault and E5 (Licensed Practical Nurse). E1 said it is the facility policy that they cannot be employed with these convictions. E1 said she suspended E2 and was going to terminate E5. E1 said she was told by Z1 (Corporate Registered Nurse) and Z3 (Vice President of Operations) she could not suspend or terminate E2 and E5 because they had valid nursing licenses. The facility's Abuse Prevention Program (11/11/11) states, "...This facility is committed to protecting out residents from abuse by anyone...This facility will not knowingly employ individuals who have been convicted of abusing, neglecting or mistreating individuals..." The facility's Health Care Worker Background Check Policy and Procedure (2/28/12) states, "Any persons convicted of committing, or attempting to commit, any crime listed in the Health Care Worker Background Check Act will be immediately terminated from conditional employment/employment.." F 354 483.30(b) WAIVER-RN 8 HRS 7 DAYS/WK, SS=F FULL-TIME DON Except when waived under paragraph (c) or (d) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Except when waived under paragraph (c) or (d) of
FORM CMS-2567(02-99) Previous Versions Obsolete

F 226

F 354

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 4 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 354 Continued From page 4 this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

F 354

This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to have a Director of Nursing for 5 days. This has the potential to affect all 59 residents in the facility. The findings include: The Facility Data Sheet of 8/9/2012 shows 59 residents reside in the facility. On 8/14/2012 at 2:30 PM, E9 (Licensed Practical Nurse) said she was the interim Director of Nursing. E9 said E2 (Director of Nursing) was terminated from employment on 8/10/2012. On 8/15/2012 at 9:00 AM, E1 (Administrator) said she did not have an interim Director of Nursing. E1 verified E2's employment with the facility was terminated. She said she was going to be doing interviews for the position. F 431 483.60(b), (d), (e) DRUG RECORDS, SS=F LABEL/STORE DRUGS & BIOLOGICALS The facility must employ or obtain the services of a licensed pharmacist who establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an
FORM CMS-2567(02-99) Previous Versions Obsolete

F 431

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 5 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 431 Continued From page 5 accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

F 431

This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to have a drug record keeping system in place to accurately dispense, control, and reconcile controlled drugs. This has the potential to affect all 59 residents
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 6 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 431 Continued From page 6 living in the facility. The findings include: The Facility Data Sheet of 8/9/2012 shows 59 residents reside in the facility. On 8/9/2012 at 10:00 AM, a review of the facility's controlled substances were was conducted with E9 (Licensed Practical Nurse/Careplan Coordinator). On 7/4/2012, E9 said an investigation was conducted regarding 14 Oxycodone tablets missing. E9 said the Controlled Drug Disposition record for the Oxycodone was also missing. Interviews were conducted with E4, E5, E6 and E7 (Licensed Practical Nurses/LPN). The tablets and the disposition record were never found. E9 said the facility policy is that controlled drugs are to be counted every shift by the going off shift and the coming on shift nurse to ensure accuracy. If the count is off, neither nurse should leave until the error is found. The Controlled Drug Disposition Forms were reviewed for R5, R6, R8, R12, and R15. Each of the residents were receiving Fentanyl patches every 72 hours for pain. On 8/9/2012 at 10:00 AM, E9 said Fentanyl patches are scheduled to be applied every 72 hours at 5:00 AM. R5 receives a 12 microgram (Mcg)/hour Fentanyl patch. On 6/24/2012, E5 applied a pain patch at 5:00 AM. E5 applied another patch on 6/25/2012. A notation on the record states E5 can't find the patch from 6/24/2012. On 6/28/2012 at 5:00 AM, E5 applied a Fentanyl patch and on 6/30/2012 at 5:00 AM, E10 (Registered Nurse) applied another patch, 1 day too soon. On 7/11/2012 at 5:00 AM,
FORM CMS-2567(02-99) Previous Versions Obsolete

F 431

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 7 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 431 Continued From page 7 E5 applied a Fentanyl Patch and she applied another patch on 7/12/2012, 2 days too soon. There is no explanation documenting why the patches were not administered as ordered. R8 receives a Fentanyl 12mcg/hr patch topically every 72 hours. On 5/20/2012, E10 applied a patch at 5:00 AM. On 5/21/2012 at 1:30 PM, E5 applied another patch. An unknown writer documents, "old one off!" On 6/29/2012 at 5:00 AM, E5 documented she applied a Fentanyl patch. On 6/30/2012 at 5 AM, E10 documented she applied another patch, 2 days early. R6 has a physician order for Fentanyl topical patches 100mcg/hr, 1 patch every 72 hours. On 7/27/2012 at 5:00 AM, a patch was applied (unknown by whom). The following day, 7/28/2012, E5 applied another patch, and she again applied a 3rd patch at 5:00 AM on 7/30/2012. The last 2 patches were applied early. R12 is to receive a 50mcg/hr Fentanyl patch every 3 days. A Fentanyl patch was applied on 6/29/2012 at 5:00 AM by E5. On 6/30/2012, E10 applied another patch at 5:00 AM. On 7/12/2012 at 5:00 AM, E5 applied a patch. On the same day at 7:30 PM, E6 applied another patch. There is no documentation on the Controlled Drug Record as to the reasoning for the 2 patches to be applied the same day, 14.5 hours later. On 7/15/2012 at 5:00 AM, E5 applied a patch (According to the physician orders and the Controlled Drug Record this was the appropriate time for the medication). Next to the entry she wrote, "Had to be replaced cause fell off on 3rd shift." E5 applied another patch the following day at 5:00 AM, with no explanation of why the patch
FORM CMS-2567(02-99) Previous Versions Obsolete

F 431

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 8 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 431 Continued From page 8 was being applied 2 days early. On 7/19/2012 at 5:00 AM, E5 applied a Fentanyl patch and again applied another patch the following day at 5:00 AM (7/20/2012). R15 has a physician order for Fentanyl 50mcg/hr patch to be applied every 3 days. On 5/26/2012 at 5:00 AM, E10 applied a patch. On 5/27/2012, E5 applied another patch at 8:00 PM. There is no explanation to why the patch on 5/27/2012 was applied early. On 6/16/2012, E10 applied a patch at 5:00 AM, and on 6/18/2012, E4 applied another patch. On 7/10/2012 at 5:00 AM, E5 applied a Fentanyl patch and E4 applied another on 7/12/2012 at 12:00 PM. There is no documentation for the reasoning of the patches being applied early. On 8/14/2012 at 2:30 PM, E9 was asked to why each of the above Fentanyl patches were not dispensed according to the physician orders and why some of the patches were falling off. E9 said, "I did not know there was a problem with the patches falling off." The facility could not provide documentation to explain why the above Fentanyl patches were applied too early. 2. A Controlled Drug Record shows the facility received 30 milliliters (ml) of Morphine on 2/16/2012 (for R15). E7 was the receiving nurse. The Controlled Drug Form for the morphine documents on 2/24/2012 at 11:00 PM, there were 4.0 ml remaining of morphine. The next entry on the Control Form is 3/4/2012. Documented, on the form, is the following; "3.5 ml correct count." The facility could not provide documentation as to what happened to the 0.5ml morphine. An investigation was not done. On 8/16/2012 at
FORM CMS-2567(02-99) Previous Versions Obsolete

F 431

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 9 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 431 Continued From page 9 12:59 PM., the facility sent to the regional office, by facsimile, a Narcotic Review document showing that 0.5ml of the drug could not be accounted for. 3. A Controlled Drug Record for R19 shows that he is to receive 0.25 ml (0.5 mg) Lorazepam oral concentrate at bedtime and he may receive 1/2 ml (1mg) every 6 hours as needed for anxiety/agitation. The record for 7/7/2012 through 7/29/2012 was reviewed. On 7/12/2012 at 5:00 AM, E4 administered 0.5 ml. E4 added the amount given to the remaining amount of Lorazepam instead of subtracting the amount. After giving the medication, E4 documented that 27.75 mls were left in the bottle. The actual count should have been 25.75 mls. This count continued inaccurately for 18 more doses of Lorazepam, showing the facility did not ensure the nursing staff were accurately reconciling medications with 2 nurses every shift. 4. The Shift Change Accountability Record Sheets were reviewed for 1/2012 through 8/8/2012. E9 said the nurse going off shift and the nurse coming on shift are to check the controlled drugs together to ensure accuracy. There were 111 spaces not filled in by one or both nurses, showing the controlled substances were not reconciled according to facility policy. All of the Controlled Drug Records were reviewed for 1/12 through 8/8/12. There were 146 entries that were scribbled out, not legible, or lined out without signatures, dates, and an explanation for the crossed out entry. On 8/8/2012 at 10:00 AM, E9 said when an error occurs on the Controlled Drug Record, the nurse should draw a single line
FORM CMS-2567(02-99) Previous Versions Obsolete

F 431

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 10 of 11

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING

PRINTED: 08/28/2012 FORM APPROVED

OMB NO. 0938-0391

______________________
(X3) DATE SURVEY COMPLETED

146084
NAME OF PROVIDER OR SUPPLIER

B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE

C
08/15/2012

PLEASANT VIEW REHAB & HCC

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

500 NORTH JACKSON STREET

MORRISON, IL 61270
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 431 Continued From page 10 through the entry, write the date, his/her initials, and the reason for the correction. E9 said the entries should never be scribbled through. The facility could not present a policy and procedure for making corrections on medical documentation. The facility's Controlled Substances policy and procedure (10/06) states, "....4. All Schedule II drugs must be administered and recorded on a disposition sheet as follows: date and time of administration, signature of nurse administering drug, and quantity on hand/balance left. 5. If a resident refuses a dose of a controlled drug, or it is not given for any reason, the medication dose must be destroyed. The dose must be destroyed in the presence of two (2) Licensed Nurses and documented on the disposition sheet as destroyed...7. The drugs in Schedule II (and those in other schedules which have been restricted and stored in the Controlled Substance cabinet) will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty...Discrepancies must be reported immediately to the Director of Nursing who shall investigate...When loss, suspected theft or an error in the administration of regulated drug occurs, a report will be filed with the Pharmacist and the Administrator..."

F 431

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: B27U11

Facility ID: IL6007504

If continuation sheet Page 11 of 11