lWinois Department of Public Health FORM APPROVED ‘STATEMENT OF DEFICIENCIES (0) PROVIDERSUPPLERCLIA [AND PLAN OF CORRECTION IDENTIFICATION NUMBER” — |, uno. 1.012470 B.WIN (0) MULTIPLE CONSTRUCTION (oa DATE SURVEY ‘COMPLETED. c 08/15/2019, [NAME OF PROVIDER OR SUPPLIER, 610 LOWRY STREET PITTSFIELD MANOR PITTSFIELD, IL 62363, 3B PREF. Ta "SUMIVARY STATEMENT OF DEFICIENCIES (GACH DEFICIENCY MUST BE PRECEDED BY FULL ©. PREF REGULATORY OR LSC IDENTIFYING INFORUATION) TAs. ‘$9999 Final Observations 9999 ‘Siatement of Licensure Violation: of 1 Violation 300.610a) 300.12100)5) 300.1210d)6) | 300.3240) | Section 300.610 Resident Care Policies 2) The facility shail have written policies and procedures governing all services provided by the fecilly. The writen policies and procedures shall be formulated by a Resident Care Policy ‘Committee consisting of at least the administrator, the advisory physician or the medical advisory commitiee, and representatives ‘of nursing and other services in the faciity. The policies shall comply with the Act and this Part ‘The written policies shall be followed in operating | the facility and shall be reviewed at least annually by this committee, documented by written, signed and dated minutes of the meeting. Section 300.1210 General Requirements for Nursing and Personal Care b) The facilty shall provide the necessary ‘care and services to attain or maintain the highest Practicable physical, mental, and psychological ‘well-being of the resident, in accordance with each resident's comprehensive resident care plan, Adequate and properly supervised nursing ‘care and personal care shall be provided to each {mole Deparment of Publ Hea LABORATORY DRECTORS OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE Electronically Signed STATE FORM Vaan (CROSS REFERENCED 10 THE APPROPRIATE. ‘STREET ADDRESS, CITY. STATE, 21° CODE ‘PROVIDERS PLAN OF CORRECTION 25), {EACH CORRECTIVE ACTION SHOULD BE DAE DEFICIENCY) AttachmentA Statement of Licensure Violations me (0 Dare 08/26/19 Tearinaionsea ToSWinois Department of Public Health _ FORM APPROVED ‘STATEMENT OF CEFICENGIES | (Kt) PROWDERSUPPLERGUN | (2) MULTIPLE CONSTRUCTION [pay parE SURVEY [AND PLAN OF CORRECTION ermmearionnawwer — |S auton couPtere c 16042470 (8. WING _______ 08/15/2019 NAME OF PROVIDER OR SUPPLIER ‘STREET ADORESS, CITY, STATE. 2 CODE ‘610 LOWRY STREET pl eee PITTSFIELD, IL_62363 m8 ‘SuNnUARY STATEMENT OF DEFOENGES © PROVIDERS PLAN OF CORRECTION =, FRER —_jeachoenclency wust Se pReceDeD ey FULL prerax (EAENCORRECTIVEACTIONSHOUD EE _coWeLETE TAG REGULATORY OR LSC ENTIFYNG INFORMATION) Tae cnOSE REFERENCED roTMeAPenOmeare “ONE ‘DEFICIENCY! 89999 Continued From page 1 resident to meet the total nursing and personal ‘care needs of the resident. Restorative meesures shall include, at a minimum, the following procedures: 5) _Allrnursing personnel shall assist and ‘encourage residents with ambulation and safe transfer activities as often as necessary in an ‘effort to help them retain or maintain their highest practicable level of functioning. 4) Pursuant to subsection (a), general nursing care shal include, at a minimum, the following and shall be practiced on a 24-hour, seven-day-a-week basis: 6) _Allnecessary precautions shall be taken to assure that the residents’ environment remains as free of accident hazards as possible. All ‘using personnel shall evaluaie residents to see that each resident receives adequate supervision and assistance to prevent accidents, Section 300.3240 Abuse and Neglect a) Anowner, licensee, administrator, ‘employee or agent of a facility shall not abuse or neglect a resident. (A, B) (Section 2-107 of the Act) This Requirement is not met as evidenced by: Based on observation, record review and Iinois Deparment of Pubhe Heath STATE FORM 9999 om veattt Weortinaton met 20f8FORM APPROVED inois Department of Public Health ‘STATEMENT OF DEFICIENCIES (Xt) PROVIDERSUPPLIERICLA | (K2) MULTIPLE CONSTRUCTION (xa) DATE SURVEY [AND PLANOF CORRECTION renrircanonnuMeER’ | puycones CCHELETED c 16012670 B.WING. 08/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, IP CODE ay 610 LOWRY STREET ee PITTSFIELO, IL 62363 om ‘SUMMARY STATENENT OF DEFICINGES 2 "PROVIDERS FLAN OF CORRECTION oa) PREF (GACH DEFIGENCY MUST BE PRECEDED BY FULL PREFIK (EACHCORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Ae CROSS-REFERENCED TOTHE APPROPRIATE ONE DEFICIENCY) ‘$9999. Continued From page 2 $9998 interview, the facily failed to provide supervision {o prevent faling for 1 of 6 residents (R2) reviewed for falls in the sample of 6. This failure resulted in R2 falling, hitting her head and being | ‘sent to the Emergency Room (ER). R2 sustained ‘a traumatic skull fracture, subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and subdural hemiatoma (a pool of blood between the brain and its outermost covering) that caused her death Finding includes: (On 02/02/19, R2 was admitted to the facility with the following diagnoses: Alzheimer's Disease, unsteadiness on feet, history of falls, anxiety and benign paroxysmal vertigo (dizziness and ‘sensation of spinning with certain head movements). R2's Minimum Data Set (MDS), dated 6/7/19, documented R2 had a Brief Interview of Mental Status (BIMS) score of 4, indicating she had severe cognitive impairment. R2's MDS. documented her balance was not steady when walking and when tuning around, The MDS documented R2 required supervision of one person for transfers and ambulation. The Care Pian, dated 05/13/19, documented R2 was at risk for falls with interventions to assist to activities and remind and encourage to call for assistance before getting out of bed or transferring. ‘On 02/02/19, a John's Hopkins Fall Risk ‘Assessment Tool was documented upon R2's admission. It documented R2 was assessed at a hhigh risk for falls due to age being greater than 80 ‘Wipals Deparment of Public Healy STATE FORM a vain eortruaon set 3019FORM APPROVED. Illinois Department of Public Health 'STATEMENTOF DEFICIENCIES | (X1) PROVIDERSUPPLERIGUA | (x2) MULTIPLE CONSTRUCTION (0G) DATE SURVEY ‘AND PLAN OF CORRECTION IDENTIFICATIONNUMBER’ — |. cunpIG (COMPLETED c 116012470 8 wing ____ 08/18/2019 [NAME OF PROVIDER OR SUPPLIER ‘STREET ADORESS, CITY, STATE, 2 CODE 610 LOWRY STREET PITTSFIELD MANOR PITTSFIELD, IL 62363, (4). “SUMMARY STATENENT OF DEFICENCES 0 "PROVIDERS PLAN OF CORRECTION SRErK (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (GOH CORRECTIVE ACTION SHOULD BE TAG REGULATORY GR LSC IDENTIFYING INFORMATION) TAG ‘CROSS REFERENCED 10 THE APPROPRIATE DEFICIENCY) $9999. Continued From page 3 s9999 years, having fallen within the last six months, currently taking two or more high fall risk drugs and behaviors of being impulsive. On 06/26/19, the John’s Hopkins Fall Risk Assessment Tool assessed R2 being no fal risk due to being unresponsive. 0n 03/07/19, R2's Accident and Incident Report documented 2 fell in the hallway while ambulating independently attempied to sil ina chair and fell face first onto floor. R2 sustained an abrasion to bridge of her nose. fown ‘On 03/08/19 at 2:43 AM, R2's Progress documented "Reminded to use call light for staff assist.” Dn 04/26/19 at 12:08 PM, an Accident and Incident Report documented R2 fell in the dining “oom while attempting to sit down. R2's Accident and Incident Report, dated 26/13/19 at 4:27 AM, documented R2 reported she had fallen out of bed sustaining 0.3, tentimeters (cm) scrape on right elbow, 4.em raised, bruised area behind right ear, pinpoint area to right ear lobe and 3 om raised area in front of right ear. It documented R2 was sent to the emergency room with negative CAT Scan report and was sent back to the facility. The physician ordered to monitor for any changes. R2’s Accident and Incident Report, dated 6/20/19 at 6:30 PM, documented R2 reported faling in the last two days. At 9:23 PM, a nurse's note documented “full body assessment was completed with left hip bruise measuring 15 cm x (by) 8 cm, dark purple in color. Resident states that's when | fell and complained of area being sore.” inots Department oT Public Wealth ‘STATE FORW om vant Meontnaton sheet 4019FORM APPROVED Winois Department of Public Health 'STATENENT OF DEFCIENCIES | (X1) PROVIDERISUPPLIERTCUA | (2) MULTIPLE CONSTRUCTION [aay DATE SURVEY [AND PLAN OF CORRECTION DENTIFICATIONNUNBER’ — |S anon cowPLETED c 1u6012470 2. WING. 08/15/2019 [NAME OF PROVIDER OR SUPPLIER ‘STREET ADORESS, CITY, STATE, ZIP CODE Irs 610 LOWRY STREET PITTSFIELD MANOR PITTSFIELD, IL 62363, Om “SUMMARY STATENENT OF DEFICIENCIES 2 ‘PROVIDERS PLAN OF CORRECTION 3) BaerK —_(GACHDEFICIENCY MUST BE PRECEDED BY FULL PERK (EACHCORRECTIVE ACTION SHOULOBE COMPLETE TRG REGULATORY OR LSC IDENTIFYING INFORMATION) TAS CROSS REFERENCED TOTHE APPROPRIATE CATE DEFICIENCY) ‘$2989 Continued From page 4 $9999) 2's Nurse's Note, dated 5/21/19 at 2:05 PM, documented R2 complained of dizziness and stated she had fallen one to two days ago. Physician order for labs with dehydration results. ‘On 0622/19, Physician's Order (PO) dated 5/22/19, documented “intravenous fluids and left hip x-ray." The left hip x-ray was negative for fracture. On 06/14/19, R2’s Nurse's Note documented R2 had "kneeled self to the floor stating she wes dizzy." ‘On 0624/19 at 9:15 AM, R2’s Nurse's Note documented R2 left in facility vehicle for dental appointment. At 10:33 AM, a nurse's note documented V4, Certified Nurse's Aide (CNA) and facility bus driver called and reported R2 had fallen while at the dentist and was sent to the emergency room via ambulance. At 12:38 PM, a ‘nurse's note documented the hospital called regarding R2 with a diagnosis of “brain bleed. (On 07/19/19 at 11:15 AM, an Accident and Incident Report log was presented and the (06/24/19 incident was not listed on the June 2019 log. On 08/02/19 at 10:20 AM, a revised Accident and Incident Report for June 2019 was presented by the V2, Director of Nursing. V2 stated the {acity had failed to report this and do an investigation. V2 stated the incident involving R2 had happened outside the facility and was not ‘aware that the log had not been updated and an official investigation had not been completed. 2's Hospital Computed Tomography (CT) scan, dated 6724/19, documented "There is acute intracranial hemorthage and a complex skull fracture which extends across the skull from right toleft” ‘nas Depart of Pub Fea STATE FORM “ ean Meontraton suet $619FORM APPROVED ins ith STATENENT OF UE"CENGES |) PROVDEREUPPLERGLA | 0) MULTI CONSTRUCTION 0) DATE SURVEY [AND PLAN OF CORRECTION ioenmmcanonnunBeR — |p cut ong coucereD c 6012470 ewe 08/15/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CY, STATE, 27° CODE 610 LOWRY STREET Ge PITTSFIELD, HL 62363, rr ‘SOWINAY STATENENT OF CEFCIENCIES 2 PROVIDERS PLAN OF CORRECTION 7, GRerx ——_(EACHDEFICIENGY MUST BE PRECEDED BY FLAL Paerx (EACHCORRECTIVE ACTION SHOULD BE COMPLETE The’ REGULATORY ORLSC IDENTIFYING INFORMATION) THe CROSS REFERENCED OTHE APPROPRIATE OME DEFICIENCY) ‘$9999 Conthued From page 5 ‘50989 R2's Hospital History and Physician (H&P), dated 6/24/19, documented the CT scan showed an extensive subarachnoid hemorrhage, subdural hemorrhage and complex skull fracture. The HAP documented the family was notified of the findings and documented "They have agreed 10 keep patient in the hospital with comfort measures only, with the understanding that patient wil likely soon pass related to the intracerebral hemorrhage,” R2’s State of llinois Certificate of Death Worksheet, dated 7/9/19, documented R2 ‘expired on 6/27/19. The cause of death documented "blunt force trauma” due to “falling and striking head on ground.” (On 08/07/19 at 3:20 PM, V5, CNA stated he had ‘worked on the locked unit for years and remembered working with R2. He stated R2 was at frst mostly independent with needing only cues | during care or direction to activities or meals. He stated toward the end before R2's death, R2 required more cueing and assistance with care ‘and more supervision. He stated she wandered throughout the unit without assist mostly but did have to have hand holding assistance while walking at times and did not know how to use her call ight for assistance. He stated R2 complained of dizziness at times, especially during showers which was twice weekly. He stated he would not leave R2 unattended outside. (On 08/07/19 at 3:30 PM, V6, CNA stated R2 was at fst independent with cueing from staff. She slated R2 was unable to use her call light or ‘remember what it was for. She stated just before her death, R2 needed more assistance with care, was incontinent at times, required more iinet Deparment of Pubic Hea STATE FORM wn vzattt Ateominuaton eet 609FORMAPPROVED Iinois Department of Public Health STATEMENT OF DEFICIENCIES | (1) PROVIDENSUPPLERIGLA | (K2) MUTILE CONSTRUCTION (RS) DATE SURVEY AND euNoF CORRECTION DEntPIcaTONNUMOER — |p win ome. COUPLED Cc 16012470 1B. WING —__£. 08/15/2019 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, 2° CODE 610 LOWRY STREET aaa PITTSFIELD, iL 62363 rr “SUAIMARY STATEMENT OF DEFIDENCES PROVIDERS PLAN OF CORRECTION = SRER | (eactbenciencr mist Be PRECEDED ev Fu, prerx (EACH CORRECTUE ACTION SHOULD BE COMPLETE TAC AEGULATORY OM SC DENTIEVING INFORMATION) Tae CROSEREPERENGED TOTME APPROPRIATE OME DEFICENCY) $9999 Continued From page 6 ‘s9999 assistance with ambulating (hand holding) and ‘complained more often of headaches and dizziness. V6 stated R2 needed extra hygiene | assistance with tolleting and would frequently take herself to the bathroom unassisted. (On 08/07/19 at 4:05 PM, V4, CNAVFacilty ‘Transportation Driver, stated she had transported R2 to the dentist on 06/24/19 and witnessed her fall. V4 stated she arrived at work that morning and was informed that R2 needed to be transported to the dentist. She stated R2 was taken via wheelchair by VB, CNA from the locked tnt to the front entrance to the facility and then ‘ambulated without a gat belt to the van with assisting R2 by grasping R2's hand to help keep her balance as she stepped into the bus and buckled her seatbelt. V4 described the van as having a double door in which R2 could step down onto the roadway next to the sidewalk of the dentist's office. When they arrived at the dentist office, the front entrance was not available, so she had to park parallel to the building. She opened the side double doors, assisted R2 with unbuckling seatbelt and with Grasping R2's hand to assist step down the step Of the van to the edge of the sidewalk. V4 then stated she continued to hold R2's hand while assisting her up two steps to the sidewalk and then turned to close the double doors and around the back to the driver's side door to park the van | ‘when she said she saw R2 fall to the ground through the van window. V4 described the van as having full windows on each side, double doors. Con the tight side with a chair lift, an emergency door at the end and a driver's side and passenger side doors. She stated she immediately ran to R2 who was attempting to sit up and saw that her head was bleeding, She stated she called 911 because she knew the injury to the head was {insle Dapatmont of Pubic Heath STATE FORM - veaint contusion shea TotFORM APPROVED. llinois Department of Public Health SSTATENENT OF DEFICIENCIES | (X1) PROVIDERVSUPPLIRICLIA | (X2) MULTIPLE CONSTRUCTION [oa) DATE SURVEY [AND PLAN OF CORRECTION enmincanonnuvaer” — |, enon ‘COMPLETED c u6012470 8. WING 08/15/2019, [NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE. ZIP CODE 610 LOWRY STREET PITTSFIELD MANOR PITTSFIELD, IL 62363 ay "SUNVARY STATENENT OF DEFICIENCIES a PROVIDERS PLAN OF CORRECTION 29) Petrik —-_(EACHOEFICIENCY MUST BE PRECEDED BY FULL PREF (GACH CORRECTIVE ACTION SHOULD BE comers HG REGULATORY ORLSC IDENTIFYING INFORMATION) TAS. (CROSS REFERENCED TO THE APPROPRIATE on y ‘$9999 Continued From page 7 ‘s9999 ‘enough to go to the emergency department. She ‘went to tur off the van and put on gloves and held pressure to R2’s head. She stated she was ‘not sure if R2 had hit her head on the van or the. concrete. She stated the county sheriff arrived, then the ambulance and R2's daughter. She stated R2 was confused and not making sense. V4 stated she did not know R2 had a history of falls or wandering or needing stand by or limited assist. V4 stated V8, CNA told her R2 could walk to the van, but needed help with the steps and seatbelt. She stated this was the first time she hhad transported R2. (On 08/07/19 at 11:01 AM, V3, R2's Physician, stated R2’s condition upon admission to the facility wes guarded due to advanced end stage Alzheimer's Disease resulting in debily and decline in mental and physical abilities. He stated the admission was after a lenathy period where the family was caring for R2. He stated R2 was admitted due to increased debility, weakness, falling, wandering and eloping from home. He stated R2 wes alert to self only and was not be ‘able to remember simple directions and had poor safety awareness. He stated R2 was ambulatory, but at times not steady due to physical decline ‘and dizziness and did require staff supervision. He stated R2 had fallen at home and the facility several times with some injuries, mostly skin tears, bruising and abrasions. He stated thal the fall on 06/24/19 certainly contributed to R2's death due to skull fracture with brain hemorrhage He stated he had been told that R2 had fallen in the community at @ dentist appointment and was left unattended while the facility van driver was parking the van, On 08/07/19 at 6:15 PM, V1, Administrator, stated the faciliy did not have a specific policy inols Deparment of Pubic Health ‘STATE FORM ee van Meontruaton sheet Bot 8FORM APPROVED, STATEMENT OF DEFICIENCIES | (1) PROVDERSUPPLERTGLA | (x2) MULTIPLE CONSTRUCTION ]poomresumey —] [AND PUAN OF CORRECTION IDENTRCAMIONNUNGER — | mow ome, COMPLETED c 116012470 —————— 8/15/2019, NAME OF PRCVDER OR SUPPLIER ‘STREET ADDRESS, CITY. STATE, ZIPCODE TTS 610 LOWRY STREET PITTSFIELD MANOR PITTSFIELD, IL 62363 rn URINARY STATENENT OF DEFENCES © 'PROVIDERS PLAN OF CORRECTION 35) PREEK —_(EACHOEPICIENCT MUST Be PRECEDED BY FULL PREF. (ACHCORRECTIVE ACTIONSHOUD BE coupteTe TAS REGULATORY OR LSC IDENTIFYING INFORMATION) Tas CAOSEHEPERENCED 10 THE APPROPRIATE OaTe ‘DerceNcr) ‘$0992 Continued From page 8 $0009 and procedure on transporting residents regarting resident's special needs, history of falls ‘or whether direct physical contact during assist was required. (On 08/12/19 at 12:35 PM, V9, Registered Nurse ARN), stated she was working on 06/24/19 and ‘ecails teling V4, CNA that R2 should be taken by ‘wheelchair from the unit to the front lobby to get ‘on the van due to it being such a long walk and R2 may become too tired. VO stated she did not specifically tell V4 of R2's falls history, dizziness ‘or transfer requirements, (On 08/12/19 at 2:00 PM, V1, stated the facility does not have a specific policy and procedure regarding how staff notify facity van drivers transporting residents of their required needs for 12 staff during transport, wandering residents or special needs during transport. V1 stated that staff rely on nursing assessments and the John's Hopkins Fall Risk Assessment Tool for ADL care and assistance needs for each resident. (a) inois Doparinant of Public Heath STATE FORM - veant eontimaton sheet 9ot8