PRINTED: 05/06/2011

FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

145278

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

______________________

C
04/28/2011

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

105 EAST 23RD STREET

STERLING PAVILION
(X4) ID
PREFIX
TAG

(X3) DATE SURVEY

COMPLETED

STERLING, IL 61081

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 000

Original Complaint Investigation

1111094/IL52505
F 323 483.25(h) FREE OF ACCIDENT
SS=G HAZARDS/SUPERVISION/DEVICES

F 323

The facility must ensure that the resident

environment remains as free of accident hazards
as is possible; and each resident receives
adequate supervision and assistance devices to
prevent accidents.

This REQUIREMENT is not met as evidenced

by:
Based on observation, interview, and record
review the facility failed to prevent a dependent
resident from falling off the side of the bed. This
failure resulted in R1 falling and being
hospitalized on 04/04/11 for treatment of
fractures her Tibia, Fibula, and Femur.
This includes 1 of 3 residents reviewed for falls
with injuries. (R1)
The findings include:
R1's Data Set of 01/04/11 shows R1 is totally
dependent with transfers and requires the
assistance of two staff. R1 does not ambulate
and is totally dependent with locomotion.
R1's plan of care updated 03/29/11 states,
"Resident is non-ambulatory uses [reclining] chair
and is dependent on care staff to propel her
to/from all desired destinations; Resident
transfers to/from all surfaces using a [total] lift
and assist of two."
On 04/14/11 at 11:05 AM, E14 (Certified Nursing
Assistant (CNA)) stated, "R1 could not bear
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

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: 2V3C11

Facility ID: IL6009179

If continuation sheet Page 1 of 4

PRINTED: 05/06/2011
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

145278
NAME OF PROVIDER OR SUPPLIER

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

C
04/28/2011

STREET ADDRESS, CITY, STATE, ZIP CODE

105 EAST 23RD STREET

STERLING, IL 61081

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 323 Continued From page 1

weight. I have never seen R1 walk, attempt to
walk or sit up at the side of her bed."
On 04/14/11 at 11:10 AM, E10 (CNA) stated, "R1
has been a [total lift] for the last year. If a
resident uses a [total lift], he or she does not bear
weight. R1 does not walk; R1 does not try to sit
up."
On 04/14/11 at 11:55 AM, E13 (CNA) stated, "I
have never seen R1 try to sit up or walk in the
last year."
On 04/14/11 at 12:30 PM, E12 (CNA) stated, "R1
has not ambulated in a little over a year.
Definitely has not been weight bearing for six
months, maybe a year or year in a half. I have
never witnessed R1 turning in bed. She is
dependent on staff for repositioning. Maybe a
year ago she was able to set up [without
assistance]."
On 04/14/11 at 12:45 PM, E15 (CNA) stated, "R1
has not ambulated in last year. R1 requires staff
assistance and verbal cues with maneuvering in
bed. R1 would require staff assistance and cues
for sitting up from laying down. She could not sit
up independently."
On 04/14/11 at 1:40 PM, E6 (CNA) stated, "I
entered R1's room, we [E5 (CNA) & E6] were
doing rounds. I saw R1 sitting up at the edge of
the bed. R1 was sitting up and I laid her down.
About five minutes later nurse and I heard 'help,
help.' We found R1 laying on the floor."
On 04//14/11 at 2:20 PM, E5 stated, "R1 was
sitting on the edge of her bed. E6 was standing
in the doorway. I asked E6 why R1 was sitting
up and E6 told me R1 wanted to get up. E6
asked me to bring her the stand-lift. I took her
the stand lift; I sat the lift in front of the door.
Then, I took linen to soiled utility room. As I was
walking into the soiled utility room, I saw E6
FORM CMS-2567(02-99) Previous Versions Obsolete

______________________

B. WING _____________________________

STERLING PAVILION
(X4) ID
PREFIX
TAG

(X3) DATE SURVEY

COMPLETED

Event ID: 2V3C11

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 323

Facility ID: IL6009179

If continuation sheet Page 2 of 4

PRINTED: 05/06/2011
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

145278
NAME OF PROVIDER OR SUPPLIER

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

C
04/28/2011

STREET ADDRESS, CITY, STATE, ZIP CODE

105 EAST 23RD STREET

STERLING, IL 61081

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 323 Continued From page 2

exiting R1's room. The lift was never moved,
when I came out of soiled utility room. About five
minutes later, I was walking toward room I had
been in, and the nurse ran into R1's room. I also
went into R1's room and R1 was on the floor.
She was on her right side with head toward the
end of bed. I think E6 left R1 on the side of the
bed and resident tried to get up. I highly doubt
E6 laid R1 down because R1 was not strong
enough to sit up by herself."
On 04/15/2011 at 1:00 PM, E7 (CNA) stated, "R1
was not physically able to sit up by herself. I
heard one of other employees sat her up and left
her there. She just left her sitting."
On 04/15/11 at 1:05 PM, E9 (CNA) stated, " R1
could not sit up by herself. R1 required staff
assistance to sit up."
On 04/15/11 at 2:00 PM, Z1 (Physician, Medical
Director) stated, " I have never seen R1 go from
laying to sitting. R1's injuries are consistent with
a fall from sitting to the floor. R1 should not be
left sitting independently. It would be unsafe to
leave R1 at beside. If R1 was sitting up and left
the fall could have been prevented."
The nursing note dated 04/04/11 at 9:30 PM
states, "Called to room by E6 (CNA) as patient
was yelling, 'help, help." Patient was on floor on
mat, head facing to door, right side of right ankle
deformed. Patient not moved. No other visible
trauma."
The facility incident report dated 04/04/11 states
"HISTORY OR PRESENT ILLNESS: Resident
observed on floor next to bed (landing strip in
place). Resident had trauma to right side lower
extremity. Power of Attorney and Physician
notified. Transferred to Emergency Room per
ambulance. Resident repositioned to EMT, 'I
was trying to get to my chair. ' Resident admitted
FORM CMS-2567(02-99) Previous Versions Obsolete

______________________

B. WING _____________________________

STERLING PAVILION
(X4) ID
PREFIX
TAG

(X3) DATE SURVEY

COMPLETED

Event ID: 2V3C11

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 323

Facility ID: IL6009179

If continuation sheet Page 3 of 4

PRINTED: 05/06/2011
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

145278
NAME OF PROVIDER OR SUPPLIER

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

C
04/28/2011

STREET ADDRESS, CITY, STATE, ZIP CODE

105 EAST 23RD STREET

STERLING, IL 61081

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

F 323 Continued From page 3

with multiple lower extremity fractures."
The hospital History & Physical from 04/04/11
states, "This is an 86-year-old demented
female...She has been non-ambulatory for over
two years and nursing there stated that she sat
up and started to get up to walk out of bed, fell on
the floor...LABORATORY/RADIOLOGY: X-rays
show bilateral tibia fractures and right distal
femur fracture that is displaced
anteriorly....PLAN: I [ER Physician] explained
that these are severe fractures. R1 is already
non-ambulatory and she has fairly severe
osteoporosis...it is unlikely she will be able to
ambulate again."

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

______________________

B. WING _____________________________

STERLING PAVILION
(X4) ID
PREFIX
TAG

(X3) DATE SURVEY

COMPLETED

Event ID: 2V3C11

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

F 323

Facility ID: IL6009179

If continuation sheet Page 4 of 4