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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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 000 INITIAL COMMENTS Annual Certification and Licensure Licensure Survey for Subpart S: SMI Complaint Investigation 1180798/IL52172 - No deficiencies 1180939/IL52342 - No deficiencies

F 000

Licensure Survey for Subpart S F 152 483.10(a)(3)&(4) RIGHTS EXERCISED BY SS=D REPRESENTATIVE In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf. In the case of a resident who has not been judged incompetent by the State court, any legal surrogate designated in accordance with State law may exercise the resident's rights to the extent provided by State law.

F 152

6/24/11

This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to obtain a guardian for 1 resident (R9). Findings include: R9 is a 66 year old male with a diagnosis of Paranoid Schizophrenia. R9 clinical record
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: HFIG11

Facility ID: IL6001994

If continuation sheet Page 1 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 152 Continued From page 1 documents that R9 has been noncompliant with taking medications, refuses programming, to take part in any activities at the facility. The MDS of 2/3/11 and the psychiatry evaluation of 10/20/10 documents that R9 has auditory hallucinations, delusional, and has poor judgement. There was no documentation by nursing or the social service department indicating that R9 had an emergency contact person, guardian or family or that social service had attempted to obtain a guardian for R9. E6 PRSC stated when interviewed that a guardian had not been obtained for R9. F 157 483.10(b)(11) NOTIFY OF CHANGES SS=D (INJURY/DECLINE/ROOM, ETC) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in 483.12(a). The facility must also promptly notify the resident and, if known, the resident's legal representative
FORM CMS-2567(02-99) Previous Versions Obsolete

F 152

F 157

6/24/11

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 2 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 157 Continued From page 2 or interested family member when there is a change in room or roommate assignment as specified in 483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section. The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member.

F 157

This REQUIREMENT is not met as evidenced by: Based on record review and interview the facility failed to notify the doctor when there was a significant change in the resident condition for 1 (R14) of 14 residents in a sample of 24. Findings include: Record review of nurses ' progress notes dated 4-6-11 at 3:00 AM R14 in room alert and verbally response complaining of stomachache, emesis noted on the floor clear with mucus, offered Mylanta 30 millimeters and vital signs taken. Record review of nurses ' progress dated 4-6-11 at 3:00 PM denotes doctor in facility resident (R14) vomiting (coffee ground emesis) no complaint of abdominal pain, doctor wrote order for resident to be transfer to hospital. Record review of physician ' s order sheet dated 4-6-11 at 3:10 PM, send patient to emergency department for upper gastrointestinal bleeding. On 4-7-11 at 10:30 AM record review of the facilities resident significant change policy denotes a significant change in the resident ' s physical, mental or psychosocial status, the licensed nurse will contact the resident ' s family and their physician. Examples of significant
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 3 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 157 Continued From page 3 changes include emesis. Interview with E3 (Director of Nursing) on 4-7-11 at 11:40 AM states she does not know why the nurse didn ' t notify the doctor after R14 had emesis early yesterday morning. F 225 483.13(c)(1)(ii)-(iii), (c)(2) - (4) SS=D 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 to the administrator or his designated
FORM CMS-2567(02-99) Previous Versions Obsolete

F 157

F 225

6/24/11

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 4 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 225 Continued From page 4 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 investigate altercations for 3 sampled resident ( R11, R17,and R20) in the sample of 24. Findings include : 1) Per R11's nurses notes dated 10/31/10, at 7:15 PM, R11 had a verbal altercation with another resident. Review of abuse investigations showed no evidence this was investigated to determine verbal abuse. During 4/7/11 Daily Status Meeting, E5 ( Social Service Director ) said she was not able to investigate this altercation to determine abuse. As a result IDPH was also not notified of the initial or final abuse investigation. R20 has multiple diagnoses including Paranoid Schizophrenia. While reviewing the Nurses' Progress Notes, a note was found attached under the 10/27/10 documentation requesting staff to "chart on incident that occurred with (R20) and (R27)." A space (few lines) were left blank between documentations on 10/27/10 and
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 5 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 225 Continued From page 5 10/30/10. There was no incident report found in the incident binder provided by the facility. During the daily meeting on 4/7/11, the information on this incident was requested. On 4/8/11 in the morning, E3 (Director of Nursing) was reminded of this request. E3 stated that she was unable to find any incident report or any additional information. E3 stated this incident occurred before she started her employment at the facility F 226 483.13(c) DEVELOP/IMPLMENT SS=E 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

6/24/11

This REQUIREMENT is not met as evidenced by: Based on record review and interview, the facility failed to follow abuse policy and procedure involving 2 sampled resident (R11 and R20) in the sample of 24., and failed to follow their abuse policy and notify the state survey agency with an initial investigation of an incident in a timely manner, and failed to provide the state survey agency with an final investigation of the incident for 1 of 24 sampled residents (R23) involved in a motor vehicle accident. Findings include : 1) Per facility's Abuse, Neglect, and Mistreatment Prvention Program Procedures, " Any incident or allegation involving abuse or mistreatment will result in an abuse investigation."
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 6 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 226 Continued From page 6 Per R11's nurses notes dated 10/31/10, at 7:15 PM, R11 had a verbal altercation with another resident. Review of abuse investigations showed no evidence this was investigated to determine verbal abuse. During 4/7/11 Daily Status Meeting, E5 ( Social Service Director ) said she was not able to investigate this altercation to determine abuse. As a result IDPH was also not notified of the initial or final abuse investigation as outlined in their abuse policy and procedure

F 226

R20 has multiple diagnoses including Paranoid Schizophrenia. While reviewing the Nurses' Progress Notes, a note was found attached under the 10/27/10 documentation requesting staff to "chart on incident that occurred with (R20) and (R27)." A space (few lines) were left blank between documentations on 10/27/10 and 10/30/10. There was no incident report found in the incident binder provided by the facility. During the daily meeting on 4/7/11, the information on this incident was requested. On 4/8/11 in the morning, E3 (Director of Nursing) was reminded of this request. E3 stated that she was unable to find any incident report or any additional information. E3 stated this incident occurred before she started her employment at the facility. Facility policy "Abuse, Neglect and Mistreatment Prevention Program" documents that employees are required to report any incident, allegation or suspicion of potential abuse, neglect, or mistreatment they observe, hear about, or suspect to the administrator or an immediate supervisor who must then immediately report it to
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 7 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 226 Continued From page 7 the administrator. On 4/6/11 at 1:00 PM, and 4/7/11 at 2:00 PM, R17 was observed in the smoking in courtyard. R17 was further observed on both occasions yelling, using foul language, with aggressive behavior toward other residents in the courtyard. On 4/6/11 R17 stated to a female resident "if you say another word, I'm going to kick your a--". E15 (nurse aide) was observed to enter the courtyard and approach R17 and asked R17 not to hit the other resident. E15 stated when interviewed that she did not report the above incident to the administrator. E15 further stated that R17 always has the above behavior but can be redirected. E1 (administrator) stated that the about incident was not reported to E1 nor was the incident documented in an incident report. According to the facility incident report dated 2/21/11 6:55pm indicates that R23 left the facility and was struck by a car. The report indicates that the facility was notified of the incident from the admitting hospital. R23 was taken to the hospital emergency room by the local police department. The report indicates that R23 was admitted to the hospital with a fracture of the knee. Accoriding to the transmission of verification report the state survey agency was initially notified of the incident of on 2/23/11 at 1:24pm. A review of the incident reports no final investigation was found.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 226

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 8 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 226 Continued From page 8 On 4/15/11 at 1:00pm E3 (Director of Nurisng), said that she was notified at home the evenin of 2/21/11 by the facility nursing staff that R23 had eloped from the facility and was involved in a motor vehicle accident, and sustained a fracture to the right lower extremity. E3 said that she only provided the initial investigation, and said since the accident didn't occur at the facility, the facility wasn't required to provide a final investigation.

F 226

According to the facility's policy initial reporting, the state survey agency will notified immediately, up to 24 hours of the written occurrence. The policy also indicates that a final investigation will be completed with finding reported to the state survey agency within 5 days of the original occurrence. F 241 483.15(a) DIGNITY AND RESPECT OF SS=E INDIVIDUALITY The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

F 241

6/24/11

This REQUIREMENT is not met as evidenced by: Based on observations and interviews, the facility failed to ensure that all residents dignity is maintained for 2 of 24 sampled residents (R1, R8), and 2 residents outside the sample (28, R29), and failed ensure 1 resident outside of the sample was dressed dignified (R26).. Findings include:
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 9 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 241 Continued From page 9 1. During the initial tour of the facility on 4/5/11 at 9:30 AM, it was observed that R29 was attempting to ambulate down the corridor while holding his pants up with his right hand. It was further observed that R29 pants were very large and did not fit R29. 2. R28, female resident was observed to have a very large amount of white chin hair. When interviewed at that time, R28 stated that she would like to have the chin hair removed. 3. It was observed that on 4/5/11 at 2:00 PM, and 4/6/11 at 12:50 PM, that R1 had a thick amount of facial hair. In addition, it was observed that R1 (on 4/5/11 at 11:00 AM) had large food stain on his shirt. 4. It was observed on 4/5/11 and 4/6/11, that R8 had a large amount of facial hair. R8 stated when interviewed that he did have to shaved by a staff member because he was blind and could not shave himself. E4 stated when interviewed on 4/6/11 at 2:45 PM, that R28, R1, and R8 did require the assistance of the staff for all activities of daily living.

F 241

1) During initial tour with E10 ( nurse aide/medical record ) on 4/5/11 at 9:46 AM, R26 was seen laying in bed with a dirty right sock with a big hole exposing his whole heel. E10 acknowledged seeing it, and as a response after it was presented to facility on
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 10 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 241 Continued From page 10 4/8/11 daily status, the facility showed receipt of purchase of socks for R26 to address the issue. F 248 483.15(f)(1) ACTIVITIES MEET SS=D INTERESTS/NEEDS OF EACH RES The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.

F 241

F 248

6/24/11

This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to design an Activity program that meet the needs 1 of 24 (R8) who is visually and mentally impaired., and failed to ensure that the activity quarterly assessment was completed for 1 resident in the sample of 24. (R6). Findings Include: R8 is a 58 year old male with diagnoses that include Blindness, Chronic Depression, and Hypertension. The plan of care dated 2/24/11 failed to document interventions/activities for R8 who is blind. R8 stated in an interview on 4/7/11 at 12:30 PM, that he would like for the facility to offer some activities for a person who is visually impaired. R8 stated that no one at the facility has ever asked R8 the type of activities that he enjoys. R1 has a diagnosis that includes mental retardation. There was no
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 11 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 248 Continued From page 11 assessment/interventions in the plan of care that addresses activities for a resident with mental retardation.

F 248

R 6 is a 62 year old admitted to the facility with medical diagnosis which includes Seizures, depression, Schizoid-Affective-Disorder, and Hypertension. Review of record on 4-6-11 at 10:00 am indicates that the last annual activity assessment was done on 4-15-10. The last quarterly assessment noted was dated 10-20-10. The next scheduled activity quarterly assessment was to have been completed on 1-20-11. It was not done. On 4-7-11 at 4:30pm, during the daily status meeting, the facility was informed of the concern. F 250 483.15(g)(1) PROVISION OF MEDICALLY SS=E RELATED SOCIAL SERVICE The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

F 250

6/24/11

This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility's social service department failed to intervene in providing 3 sampled residents ( R 10, 16, and 18 ) psychiatric rehab in the sample of 24, and failed to provide social service interventions for 1 of 24 sampled (R1), assessed with mental retardation. The facility also failed to provide social services to meet the psycho-social needs for 1 of 24 sampled
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 12 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 250 Continued From page 12 residents (R23), an identified offender and assessed not capable of unsupervised outside pass privledges

F 250

Findings include: 1) R18 has diagnoses of Schizoaffective Disorder and Major Depression. Per R18's PAS/MH screen done on 7/9/02, R18 needs psychological rehab and medication monitoring, and that R18 should attend AA meetings. During initial tour on 4/5/11 at 9:46 AM with E10 ( CNA/ Medical record ), R18 was not in the room nor in the facility. Per E10, R18 goes out of the facility to see his family everyday. Review of R18's nurses notes indicated that R18 is out of the facility in the following dates: 8/28/10, 9/1/10, 9/8/10, 9/9/10, 9/11/10, 9/18/10, 9/20/10, 12/25/10, 1/5/11, 1/8/11, 1/24/11, 2/4/11, 2/12/11, 3/5/11, 3/26/11, and 4/6/11. According to the facility's psych groups, R18 is not attending any of the groups provided in the facility, despite of indication that R18 had behavioral episodes related to his psych diagnosis. Per Social service notes written by E6 ( case worker ) dated 10/20/10, R18 was hospitalized in August 2010 due to auditory hallucinations. Similarly on 2/16/11 at 4:30 PM, R18 was sent to the hospital with suicidal ideation, and was readmitted back to the facility on 2/23/11 per nurses notes. R18's social service
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 13 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 250 Continued From page 13 notes do not indicate what the facility put in place to address his psychiatric behavior and diagnosis, and what was put in place to satisfy his recommended psychiatric rehabilitation. During 4/8/11 interview with E6 at 3:49 PM, E6 confirmed that R18 signs out of the facility and visits his sister. E6 also confirmed that R18 does not attend any psychiatric program at this time. 2) R10 was admitted to the facility on 7/14/10 with diagnoses of Bipolar Disorder and Depression. Per state police background check, R10 is also a sex offender. Review of R10's PAS/MH screen dated 12/4/08, R10 requires psychiatric rehabilitation services. Per R10's facility social service assessment, R10 is suppose to attend a Human Sexuality Group. Per attendance sheet for the Human Sexuality Group for the month of October 2010, November 2010, and December 2010, there was no indication that R10 had attended the Human Sexuality group for months. For 2011, R10 also did not attend the same group on 1/4/11, 1/18/11, and 2/1/11. When E8 ( Psych rehab aide ) was interviewed on 4/7/11 at 10:40 AM, E8 explained that she started in September 2010 and did not conduct any psych rehab groups until around October or November 2010. E8 said that she did not know that R10 is suppose to attend the Human Sexuality Group until in January 2011, she saw that R10 has a care plan to attend the
FORM CMS-2567(02-99) Previous Versions Obsolete

F 250

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 14 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 250 Continued From page 14 said group. E8 continued that there was a list of the residents under the specific groups but that she is not sure if R10's name was in the list that time. 3) R16 has diagnosis of Paranoid Schizophrenia and was admitted to the facility of 8/31/10. Per PAS/ MH Level II Notice of Determination dated 9/14/10, the special services to be provided for R16 include the following : a) Mental Health rehabilitation activities b) Illness self -management c) Incentive program to improve participation in treatments d) Community reintegration activities During interview on 4/8/11 at 11:30 AM, R16 said that he does not attend any programs or groups in the facility, nor has he talked to any case worker. Review of the in house groups in the facility indicated that R16 attends only 1 group : Medication Compliance group. During 4/8/11 interview with E6 at 3:45 PM, E6 said that originally R16 was under 3 different case workers prior to E6. E6 said that R16 is very stubborn and one cannot have R16 go to attend groups. 2. R1 is a 59 year old male with diagnoses that include Schizophrenia, Paranoid, and Metal Retardation. R1 was admitted to the facility on 5/7/10. The initial MDS (minimum data set) documents that R1 is mildly cognitively impaired
FORM CMS-2567(02-99) Previous Versions Obsolete

F 250

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 15 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 250 Continued From page 15 and has poor decision making skills. There was no documentation in the clinical record since admission indicating the the social service department had attempted to have R1 evaluated for mental retardation services/workshops be an outside agency. E5 (social service director) stated when interviewed on 4/7/11 at 3:00 PM, that some attempts had been made to have R1 evaluated for mental retardation services but these attempts had not been documented in R1's record.

F 250

3.) According to R23's criminal history analysis report dated 3/15/10 indicates that R23 is an identified offender with a history of sexual aggression. R23 was assessed to be moderate risk indicating R23 requires closer supervision and more frequent observations that standard or routine. According to R23 current care plan dated 12/7/10 there was no care plan developed to supervise or frequently monitor R23. There was no plan of care intergrating R23 assessment of being at moderate risk requiring closer supervision, and frequent monitoring of R23. According to R23's clincal record community survival skills assessment dated 2/18/11 indicates in the note that R23 continues to be at pass level 1 (restriction), due to leaving the facility unathorized on 2/17/11. The note indicates that R23 returned to the facility late around 9:00pm. The following page indicates
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 16 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 250 Continued From page 16 that R23 is not an elopment risk, and has no history of elopment. According to R23's current plan of care dated 12/7/10 no care plan was developed after R23 elopement from the facility on 2/17/11. According to the facility incident report dated 2/21/11 6:55pm indicates that R23 left the facility and was struck by a car. The report indicates that the facility was notified of the incident from the admitting hospital. R23 was taken to the hospital emergency room by the local police department. The report indicates that R23 was admitted to the hospital with a fracture of the knee On 4/15/11 at 2:00pm E7 (social service), said that he was the responsible case worker for R23, E7 said that when residents display behaviors that care plans are developed with interventions. E7 said that care plans are developed when behaviors are new and becomes a pattern or if they are serious in nature. E7 said that elopement was serious in nature. E7 said he was aware of R23 background, as an identified offender, and history of sexual aggression. E7 said he was aware of R23 leaving the facility unauthorized on 2/17/11, E7 was unable to verbalize why he didn't develop a plan of care with interventions related to his recent behavior of elopement. On 4/15/11 at 1:30pm E5 (social service director), said that R23 left the facility unauthorized on 2/17/11, E5 said if a residents leaves unauthorized it is considered an elopement. E5 said when a resident displays this
FORM CMS-2567(02-99) Previous Versions Obsolete

F 250

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 17 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 250 Continued From page 17 behavior the psycho-social caseworker should develop a plan of care with interventions to deter / prevent R23 from future incidents of elopement. E5 said that the facility's policy is to update care plans quarterly and as needed. E5 explained that as needed is per incident or behavior care plans should be reviewed and updated with interventions. E5 said that R23 should have been re-assessed to be at risk for elopement. F 253 483.15(h)(2) HOUSEKEEPING & SS=E MAINTENANCE SERVICES The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

F 250

F 253

6/24/11

This REQUIREMENT is not met as evidenced by: Based on observation, and interview, the facility failed to ensure that housekeeping and maintenance services were done to maintain a sanitary, orderly, and comfortable interior. Findings Included: During the initial tour on 4-5-11 at 9:45 am, accompanied by E 3(Director of Nursing), the following were observed : 1. Room 21-02-Cabinets with dried flaky unknown substance cabinet bottom, Bathroom-tub no anti-slip strips, no paper drying towels, 2-3-pronged towel rack above tub loose, tub rubber water stopper plug rusted color. 2. Room 21-03-Bathroom-2,3 pronged towel racks loose above the tub, room-1 window blind broken. 3. Room 21-04-Bathroom-2,3 pronged towel racks
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 18 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 253 Continued From page 18 loose above the tub, tub no anti slip strips. 4. Room 21-05-Room-1 light fixture below cabinets, no light cover, no bulb, bathroom-mold like substance running across the top of the floor wall heater, 2, 2-pronged towel racks loose, the tip of 1 towel rack edge is broken and jagged, bed # 1-bed spread with a dried circular stain, bed # 2bed spread with a large squared stain, pillow without a pillow case. 5. Room-21-06- Light fixture below cabinet no cover, 1 missing bulb, privacy curtain dirty with multiple dried stains. 6. Room 21-07-Bathroom door broken with a fist sized hole. 7. Room 21-08-bathroom no towel racks, no paper towels, towel rack missing with exposed wall brace on wall, no soap. 8. Room 21-09-bathroom- no paper towels. 9. Room 21-11-1 privacy curtain bar loose at the ceiling. 10. Room 21-12 -bathroom no paper towels. During the environmental tour on 4-7-11, at 10:45 am, accompanied by E 14(Maintenance), the following were observed : 1. Dumpster areaketchup appearing dried stain on the ground. 2. Basement window well cover damaged with food paper debris inside of window well. 3. 21-Court Yard- 1 metal swing set with 1 foot rest plank not secured , 1 metal swing set with 1 back support plank not secured. 4. Basement stairwell- 1 ceiling speaker system noted junction box not covered with exposed wiring. 5. Laundry Roomwashing machine noted 5 strips of duct tape in contact with the cover. 6. Boiler Room- laundry room items such as linens, towels, and chemical cleaning agents stored on a cabinet. 7. 2133-Recreational Room- 1st floor- wall heating cover loose not secured. 8. Room 33-01-ceiling paint peeling in corner, below window 1 vertical wall crack, water temperature sink 83 degrees
FORM CMS-2567(02-99) Previous Versions Obsolete

F 253

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 19 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 253 Continued From page 19 Fahrenheit. Room 33-02-bathroom-ceramic wall tiles loose/cracked, sink loose, not secured on wall, no towels. 9. Room 33-05-bathroom-musty smell, above mirror 6 missing ceramic wall tiles, tub water rubber stopper rust colored. 10. Room 15-04-1 privacy curtain ripped. 11. Room 15-06-bathroom-above mirror 3 missing ceramic tiles. 12. Hallway next to room 15-12- 1 cracked window, 16 hallway windows with 6 missing screens. 13. 15-Court Yard- 1 metal swing set with 1 loose foot bar plank, 1 metal swing set with 1 loose back support bar plank, 2 metal swing sets with 1 bent seat bar planks. 14. Room 07-06-Bathroom-window cracked. Roomceiling light bulb cover cracked and not secured. 15. Room 07-04-Urine on the floor underneath the window, bathroom- no towels. 16. Room 07-08-bathroom no towels. 17. Room 07-10-bathroom sink drain plug immovable, stuck in the open position. On 4-7-11 at 4:30pm, during the daily status meeting, the facility was notified of the concerns related to the initial tour and the environmental tour. aaa) During initial tour with E10 ( nurse aide ) on 4/5/11 at 9:46 AM, the following were observed : a) Room 7 and 8 in building 33 has lamps with no lampshade. There were also missing tiles in Room 8's toilet and a broken closet door. The lamp in room 6 of building 33 is also not working. b) There is a mop in the tub of room 2 building 15. c) lamp that is not working in rooms 6 and a lamp without lampshade in room 12 of building 15.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 253

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 20 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 279 483.20(d), 483.20(k)(1) DEVELOP SS=D COMPREHENSIVE CARE PLANS A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4).

F 279

6/24/11

This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to put in place care plans that are individualized and measurable for 5 sampled residents ( R2,R3, 10, 11, and 16) in the sample of 24, and failed to develop and individualized plan of care for 1 of 24 sampled residents (R23) identified as an elopement risk, subsequently R23 eloped from the facility and was involved in a motor vehicle accident. Findings include:

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

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 21 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 279 Continued From page 21 1) R3 had multiple falls on 3/6/11 and 3/9/11. R3's care plan for falls dated 3/16/11 was noted without a goal or objective. The intervention also was not updated to put in place interventions for 3/16/11 and 3/9/11 falls. During 4/7/11 interview with E23 ( care plan nurse ), E23 was not able to explain what caused R3 to fall on 3/6/11 and 3/9/11. E23 was also not able to explain why there was no goal in R3's fall care plan, nor why there were no new interventions each time R3 falls. She added that although it is not found in the care plan, R3 should be assisted by staff if his gait becomes unsteady. When asked how the direct care staff like the nurses aide will know that if it is not in the care plan, E23 did not respond. R3 also had significant weight losses in November 2010 ( 22.8 % ), December 2010 ( 25 % ), February 2011 ( 25 % in 6 mths ), and in March 2011 ( 28 % in 6 mths ). This were not reflected in R3's weight loss care plan, nor were there individualized interventions for each weight loss. There also was no goal. The care plan in R3's record is a generic care plan with R3's name and the date 2/25/11 when the care plan was initiated. R3's outside pass care plan and criminal behavior care plan dated 2/25/11 has goals that was not measurable as it only indicates R3 to behave in a "safe and respectful manner" which was not specified. R3's specialized rehab care plan indicated as intervention that he will attend a day program 2;6
FORM CMS-2567(02-99) Previous Versions Obsolete

F 279

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 22 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 279 Continued From page 22 x per week but it does not indicate which program. R3's psychoactive meds care plan does not specify the end date of the 2/25/11 care plan. 2) R11's 2/10/11 Paranoia care plan does not have specific goals that were measurable . R11's record also showed no indication that R11 had paranoia about being poisoned thru food, yet there is a care plan goal indicating that R11 will eat food from trays without fear of poisoning. R11's outside pass care plan and criminal behavior care plan dated 2/9/11 has goals that was not measurable as it only indicates R11 to behave in a "safe and respectful manner" which was not specified. R11's care plan for behavioral aggression does not show incidents of altercations and R11 had several. The goal indicates that the resident will refrain from abusive behaviors rather than decrease the incidents of these behavior. 3) R10's fall risk care plan does not indicate when he fell and what interventions were put in place each time R10 fell on 3/9/11 and 3/16/11. The goals were also does not reflect the end date of the goal and the goal that states R10's fall will decrease is just not specific as to how few will the fall incidents decrease to. 4) R16 has multiple elopement incidents although he is not suppose to be outside of the facility unsupervised. His care plan dated 1/18/11 however does not indicate it was revised to address his violating of facility's pass privilege
FORM CMS-2567(02-99) Previous Versions Obsolete

F 279

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 23 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 279 Continued From page 23 multiple times. There were no interventions put in place to prevent him from eloping. The care plan goal as well does not specify what is " safe and respectful manner" when outside of the facility. R16 has not been in any program aside from Medication Compliance group. He has a Step of faith Program intended for him however that is dated 1/18/11, which is to address his psychiatric issues. There is no indication of the revision of care plan as R16 is not attending this program. 2.) R 2 is a 82 year old admitted to the facility with diagnosis which includes Bipolar, Paranoid Schizoid, Anemia, Dementia, and Parkinson's Disease. Review of record indicates that on 1-24-11, resident began to receive medical topical treatments related to a a skin fungal infection involving the feet. Review of the care plans does not indicate a care plan initiated. on 4-6-11 at 4:30pm, during the daily status meeting, the facility was notified of the concern. The facility did not respond to the concern. 3.) According to R23's criminal history analysis report dated 3/15/10 indicates that R23 is an identified offender with a history of sexual aggression. R23 was assessed to be moderate risk indicating R23 requires closer supervision and more frequent observations that standard or routine. According to R23 current care plan dated 12/7/10 there was no care plan developed to supervise or frequently monitor R23. There was no plan of care intergrating R23 assessment of being at moderate risk requiring closer supervision, and frequent monitoring of R23.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 279

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 24 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 279 Continued From page 24 According to R23's clincal record community survival skills assessment dated 2/18/11 indicates in the note that R23 continues to be at pass level 1 (restriction), due to leaving the facility unathorized on 2/17/11. The note indicates that R23 returned to the facility late around 9:00pm. The following page indicates that R23 is not an elopment risk, and has no history of elopment. According to R23's current plan of care dated 12/7/10 no care plan was developed after R23 elopement from the facility on 2/17/11. According to the facility incident report dated 2/21/11 6:55pm indicates that R23 left the facility and was struck by a car. The report indicates that the facility was notified of the incident from the admitting hospital. R23 was taken to the hospital emergency room by the local police department. The report indicates that R23 was admitted to the hospital with a fracture of the knee On 4/15/11 at 2:00pm E7 (social service), said that he was the responsible case worker for R23, E7 said that when residents display behaviors that care plans are developed with interventions. E7 said that care plans are developed when behaviors are new and becomes a pattern or if they are serious in nature. E7 said that elopement was serious in nature. E7 said he was aware of R23 background, as an identified offender, and history of sexual aggression. E7 said he was aware of R23 leaving the facility unauthorized on 2/17/11, E7 was unable to verbalize why he didn't develop a plan of care
FORM CMS-2567(02-99) Previous Versions Obsolete

F 279

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 25 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 279 Continued From page 25 with interventions related to his recent behavior of elopement. On 4/15/11 at 1:30pm E5 (social service director), said that R23 left the facility unauthorized on 2/17/11, E5 said if a residents leaves unauthorized it is considered an elopement. E5 said when a resident displays this behavior the psycho-social caseworker should develop a plan of care with interventions to deter / prevent R23 from future incidents of elopement. E5 said that the facility's policy is to update care plans quarterly and as needed. E5 explained that as needed is per incident or behavior care plans should be reviewed and updated with interventions. E5 said that R23 should have been re-assessed to be at risk for elopement. According to the facility's care plan policy, plans of care are to be provided for each resident and developed to meet that residents special needs. The plan of care should identify the residents need, determine the professionals involved in the care, the type of care provided along with the responsible discipline, measurable outcomes and time objectives, along with reviewing evaluating and updating as necessary, but at least quarterly. The policy indicates that all department meet weekly to discuss individual residents, and based on any change of condition care plans are updated F 280 483.20(d)(3), 483.10(k)(2) RIGHT TO SS=E PARTICIPATE PLANNING CARE-REVISE CP The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to
FORM CMS-2567(02-99) Previous Versions Obsolete

F 279

F 280

6/24/11

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 26 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 280 Continued From page 26 participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

F 280

This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to revised care plan to meet residents' need for 8 sampled residents (R1, R8, R9, R10, R14, R16, R17 and R23 ) in the sample of 24. Findings include a.) 1) R10's fall risk care plan does not indicate when he fell and not revised to show interventions each time R10 fell on 3/9/11 and 3/16/11. The goals were also does not reflect the end date of the goal and the goal that states R10's fall will decrease is just not specific as to how few will the fall incidents decrease to. 2) R16 has multiple elopement incidents although
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 27 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 280 Continued From page 27 he is not suppose to be outside of the facility unsupervised. His care plan dated 1/18/11 however does not indicate it was revised to address his violating of facility's pass privilege multiple times. There were no interventions put in place to prevent him from eloping. The care plan goal as well does not specify what is " safe and respectful manner" when outside of the facility. R16 has not been in any program aside from Medication Compliance group. He has a Step of faith Program intended for him however that is dated 1/18/11, which is to address his psychiatric issues. There is no indication of the revision of care plan as R16 is not attending this program. b.) 1. R1 is a 59 year old male with diagnoses that include Schizophrenia, Paranoid, and Metal Retardation. R1 was admitted to the facility on 5/7/10. The initial MDS (minimum data set) documents that R1 is mildly cognitively impaired and has poor decision making skills. The care plan dated 3/31/11 failed to include plans and intervention for R1's mental retardation. 2. R8 is a 58 year old male with diagnoses that include Blindness, Chronic Depression, and Hypertension. The plan of care dated 2/24/11 failed to document interventions for R8's depression and activities for a blind resident. 3. R9 is a 65 year old male with a diagnosis of Paranoid Schizophrenia. The MDS (minimum data set) documents that R9 has poor decision making skills, is non compliant with taking medications. Nursing documented in the record
FORM CMS-2567(02-99) Previous Versions Obsolete

F 280

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 28 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 280 Continued From page 28 from 12/1/10 to 4/1/11 that R9 had many episodes of altercations with other residents in the facility and There was no documented interventions to obtain a guardian/power of attorney. The plan reassessing ways to have R9 to become compliant with medications or interventions to decrease R9's altercations with other residents. 4. R17 is a 60 year old male with a diagnosis of Schizophrenia-Chronic Paranoid Type. A review of R17's plan of care documents that the plan has not been updated since 1/25/11. E4 (director of nursing) stated when interviewed on 4/8/11 at 4:00 PM, that all the above residents plans of care should have been updated at least quarterly during the care plan meetings. c.)According to R23's clinical record dated 2/1/11 R23 was involuntarily petitioned out of the facility for physical aggression toward a co-peer. According to R23's current care plan dated 12/7/10 R23 is identified with a history of verbal aggression to peers, R23 also noted to have been involved in a physical altercation with a co-peer 7/2/10. This care plan was last updated 12/7/10 According to R23 clinical record social service note 2/2/11 R23 was sent out of the facility for being involved in a physical altercation with another co-peer. The note indicate that R23 hit another resident in the head with a chair. On 4/15/11 at 2:00pm E7 (social service), said that he was the responsible case worker for R23,
FORM CMS-2567(02-99) Previous Versions Obsolete

F 280

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 29 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 280 Continued From page 29 E7 said that when residents display behaviors that care plans are developed or revised if the behavior is already identified. E7 said that care plans are revised / updated when resident repeat behaviors and current interventions are not working. E7 said that he was aware of R23 incident occurring 2/2/11 where R23 hit another resident with a chair in the head. E7 said that R23 was petitioned out of the facility, for the occurrence. E7 said that when R23 returned to the facility he counseled R23 about the inappropriateness of hitting other residents with objects. E7 was unable to verbalize why he didn't update R23's care plan with new interventions to deter R23 from physical aggression after the incident of 2/211. According to the facility's care plan policy, plans of care are to be provided for each resident and developed to meet that residents special needs. The plan of care should identify the residents need, determine the professionals involved in the care, the type of care provided along with the responsible discipline, measurable outcomes and time objectives, along with reviewing evaluating and updating as necessary, but at least quarterly. The policy indicates that all department meet weekly to discuss individual residents, and based on any change of condition care plans are updated.

F 280

d.) Record review of R14 ' s care plan notes dated 10-12-10; R14 was involved with another peer that was verbal and physical. Goals/objectives for R14 to participate with the conflict resolution group that meets in-house once a week and stress management group once
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 30 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 280 Continued From page 30 a week. Record review of care plan dated 12-10-10; R14 was involved in an incident where he punched his peer in the nose. Approaches/intervention; resident will be prompted to attend stress management group and conflict resolution group. Both meet once a week. Record review of care plan dated 1-19-11; R14 accused a peer of wearing his shirt and attempted to remove it off his peer. During incident R14 grabbed the peer by the neck and shirt. Approaches/interventions continue to prompt resident to maintain his attendance in conflict resolution group and stress management group; meet in each group once a week. Interview with E5 (Psychiatric Rehabilitation Services Director) at 2:48 PM on 4-7-11 states after R14 ' s incidents care plan should have been updated. Interview with E6 (Psychiatric Rehabilitation Services Counselor) on 4-8-11 at 9:30 AM states he did not know that R14 was already in conflict resolution after the incident on 12-10-10. E6 states he did not change any interventions from the incident in 1-19-11; just continued the same interventions stress management and conflict resolution. E6 states he should have prepared a care plan with added interventions after the 2-13-11 incident. E6 states he kept R14 in the same programs and adding different interventions should have been tried. Record review of the social service incident dated 2-13-11, R14 physically attacked another resident because that particular person grabbed his soft drink. F 281 483.20(k)(3)(i) SERVICES PROVIDED MEET SS=D PROFESSIONAL STANDARDS
FORM CMS-2567(02-99) Previous Versions Obsolete

F 280

F 281

6/24/11

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 31 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 281 Continued From page 31 The services provided or arranged by the facility must meet professional standards of quality.

F 281

This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview the facility failed to fully assess 2 of 6 (R30, R31) residents vital signs and pain intensity prior to administering medications during the morning medication pass, and failed to follow their incident reporting policy for 1 of 24 sampled residents (R23). Findings include: 1. During the morning medication pass on 4/6/11 that began at 8:50 AM, E17 (nurse) was observed to prepare medications for R30. E17 was observed to give R30 Nifedipine ER 30 mg. In addition, E17 was observed failing to take R30's blood pressure prior to giving the Nifedipine. A review of the physician's order sheet dated 4/1/11 and MAR (medication administration report) included instructions that prior to administering the Nifedipine the nurse should obtain and record R30's blood pressure. E17 stated when interviewed at this time that she did not take R30's blood pressure before administering the Nifedipine because R30 has his pressure readings done at least twice a week. E4 (director of nursing) stated in an interview on 4/20/11 at 3:00 PM, that the staff nurses should always follow the physician's order for vital signs
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 32 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 281 Continued From page 32 when administering cardiac and high blood pressure medications. 2. Facility policy "Pain Assessment" documents that residents should be asked to describe pain on a scale of 1-10 or facial grimes. Assess the location of the pain and type of the pain. Residents to be re-evaluated for drug effectiveness and if the pain is not relieved in a 30 minutes to one hour interval, the doctor should be notified. R31 was asked by E17 during the administration of R31's morning medication pass if he required any medication for pain. R31 stated that he did need pain medication. E17 was observed failing to ask R31 to describe the intensity of the pain. E17 administered Tylenol 325mg, 2 tablets. E3 (director of nursing) stated in an interview on 4/20/11 at 3:00 PM, that pain assessment by the nurse prior to giving a resident medication for pain is the practice and policy of the facility.

F 281

According to R23's clinical record community survival skills assessment dated 2/18/11 indicates in the note that R23 continues to be at pass level 1 (restriction), due to leaving the facility unauthorized on 2/17/11. The note indicates that R23 returned to the facility late around 9:00pm. The following page indicates that R23 is not an elopement risk, and has no history of elopement. On 4/15/11 at 2:00pm E7 said he didn't complete an incident report for R23's unauthorized absence from the facility on 2/17/11. E7 said that
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 33 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 281 Continued From page 33 he thought it was the responsibility of the nursing service to complete the incident report. E7 said that he was aware that On 4/15/11 at 2:15pm E5 (social service director), said that she was aware that R23 was absent without authorization on 2/17/11, E5 said there should have been an incident report completed per the facility policy. E5 said that the report could have been completed by either nursing service or the social service department. On 4/15/11 at 3:00pm E3 (director of nursing), said that she was aware that R23 left the facility on 2/17/11, but didn ' t complete an incident report. F 285 483.20(m), 483.20(e) PASRR REQUIREMENTS SS=D FOR MI & MR A facility must coordinate assessments with the pre-admission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and effort. A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental illness as defined in paragraph (m)(2) (i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission; (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of
FORM CMS-2567(02-99) Previous Versions Obsolete

F 281

F 285

6/24/11

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 34 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 285 Continued From page 34 services, whether the individual requires specialized services for mental retardation. (ii) Mental retardation, as defined in paragraph (m)(2)(ii) of this section, unless the State mental retardation or developmental disability authority has determined prior to admission-(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for mental retardation. For purposes of this section: (i) An individual is considered to have "mental illness" if the individual has a serious mental illness defined at 483.102(b)(1). (ii) An individual is considered to be "mentally retarded" if the individual is mentally retarded as defined in 483.102(b)(3) or is a person with a related condition as described in 42 CFR 1009.

F 285

This REQUIREMENT is not met as evidenced by: Based on record review, and interviews, the facility failed to obtain a pre-admission screening for 1 of 24 (R8) sampled residents. Finding include: R8 is a 58 year old male who was admitted to the facility on 7/29/09 with a diagnosis of Chronic Depression. A review of the record failed to contain a pre-admission screening and resident review assessment for R8 that indicated that R8 required specialized services. The MDS (minim
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 35 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 285 Continued From page 35 data set) codes R8 as not being a resident with severe mental illness. E5 (director of social services) stated when interviewed that R8 does have a history of depression but was not sure if R8 required specialized services. F 309 483.25 PROVIDE CARE/SERVICES FOR SS=E HIGHEST WELL BEING Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

F 285

F 309

6/24/11

This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide an ongoing assessment for 1 (R12) of 24 residents in the sample by not doing a serum level on an anticonvulsant medication, and failed to fully assess 2 of 6 (R30, R31) residents vital signs and pain intensity prior to administering medications during the morning medication pass Findings include: a. R12 has multiple diagnoses including Seizure disorder and Hepatitis C. The April 2011 Physician Order Sheet indicated that he had orders for anticonvulsant medications of Phenytoin Ex Cap (Dilantin) 200 mg (milligrams) by mouth twice daily and Carbamazepin 200 mg
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 36 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 309 Continued From page 36 by mouth three times daily. There was an order to obtain the Dilatin level evey 6 months. There was no laboratory result found in the clinical record for the Dilantin level. On 4/7/11 at 2:20 PM, E3 (Director of Nursing) stated that the Dilantin level order was not done and she had lab do it. On 4/6/11 at 12:25 PM, R12 stated that he had a seizure last week and he woke up in his bed and could not remember what happened to him. The Nurses' Notes dated 3/31/11 documented that R12 was drooling in church and a church member had to bring R12 back to the facility. There was no plan of care found in the clinical records for the seizure disorder.

F 309

b. During the morning medication pass on 4/6/11 that began at 8:50 AM, E17 (nurse) was observed to prepare medications for R30. E17 was observed to give R30 Nifedipine ER 30 mg. In addition, E17 was observed failing to take R30's blood pressure prior to giving the Nifedipine. A review of the physician's order sheet dated 4/1/11 and MAR (medication administration report) included instructions that prior to administering the Nifedipine the nurse should obtain and record R30's blood pressure. E17 stated when interviewed at this time that she did not take R30's blood pressure before administering the Nifedipine because R30 has his pressure readings done at least twice a week. E4 (director of nursing) stated in an interview on
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 37 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 309 Continued From page 37 4/20/11 at 3:00 PM, that the staff nurses should always follow the physician's order for vital signs when administering cardiac and high blood pressure medications. 2. Facility policy "Pain Assessment" documents that residents should be asked to describe pain on a scale of 1-10 or facial grimes. Assess the location of the pain and type of the pain. Residents to be re-evaluated for drug effectiveness and if the pain is not relieved in a 30 minutes to one hour interval, the doctor should be notified. R31 was asked by E17 during the administration of R31's morning medication pass if he required any medication for pain. R31 stated that he did need pain medication. E17 was observed failing to ask R31 to describe the intensity of the pain. E17 administered Tylenol 325mg, 2 tablets. E3 (director of nursing) stated in an interview on 4/20/11 at 3:00 PM, that pain assessment by the nurse prior to giving a resident medication for pain is the practice and policy of the facility. F 323 483.25(h) FREE OF ACCIDENT SS=J HAZARDS/SUPERVISION/DEVICES 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.

F 309

F 323

6/24/11

This REQUIREMENT is not met as evidenced


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

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 38 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 38 by: Based on interview and record review the facility failed to monitor, provide supervison and prevent the elopement of 1 sampled resident from a sample of 24 (R23). R23 was identified as being unable to access the community without supervision, and R23 is also an identified offender assessed to be moderate risk requiring supervision and frequent monitoring. This failure resulted in R23 eloping from the facility, and was involved in a motor vehicle accident, sustaining a fracture to the right lower extremity. These failures resulted in an Immediate Jeopardy. These failure has the potential to effect 24 current residents identified to be at risk for elopement. B. The facility also failed to ensure that 2 cognitively impaired resident ( R10 and R16 ), one of which ( R10 ) is a registered child sex offender with a psychiatric diagnosis of Bipolar Disorder in the sample of 24, is not allowed to leave the facility unsupervised. C. The facility also failed to protect resident from abusive resident for 2 of 14 residents (R14, R17) in sample of 24. D. During the environment tour the following hazards were identified.

F 323

A.)E1 (Administrator), was notified of the Immediate Jeopardy on April 13, 2011 at 10:05am via telephone conference. The Immediate Jeopardy began on 2/21/11 when the
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 39 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 39 facility was notified by the hospital that R23 was admitted after being involved in a motor vehicle accident, and sustained a fracture to the right lower extremity. Findings include: According to R23's criminal history analysis report dated 3/15/10 indicates that R23 is an identified offender with a history of sexual aggression. R23 was assessed to be moderate risk indicating R23 requires closer supervision and more frequent observations that standard or routine. According to R23 current care plan dated 12/7/10 there was no care plan developed to supervise or frequently monitor R23. There was no plan of care intergrating R23 assessment of being at moderate risk requiring closer supervision, and frequent monitoring of R23. According to R23's clincal record community survival skills assessment dated 2/18/11 indicates in the note that R23 continues to be at pass level 1 (restriction), due to leaving the facility unathorized on 2/17/11. The note indicates that R23 returned to the facility late around 9:00pm. The following page indicates that R23 is not an elopment risk, and has no history of elopment. According to the facility incident report dated 2/21/11 6:55pm indicates that R23 left the facility and was struck by a car. The report indicates that the facility was notified of the incident from the admitting hospital. R23 was taken to the hospital emergency room by the local police
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 40 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 40 department. The report indicates that R23 was admitted to the hospital with a fracture of the knee. On 4/15/11 at 1:30pm E5 (social service director), said that R23 left the facility unauthorized on 2/17/11, E5 said if a residents leaves unauthorized it is considered an elopement. E5 said when a resident displays this behavior the psycho-social caseworker should develop a plan of care with interventions to deter / prevent R23 from future incidents of elopement. E5 said that R23 should have been re-assessed to at risk for elopement. According to R23's current plan of care dated 12/7/10 no care plan was developed after R23 elopement from the facility on 2/17/11. According to R23's nursing note dated 2/21/11 8:00pm indicates that at 5:30pm R23 left the facility. 6:55pm indicates that the hospital called notifying the facility that R23 was at the hospital, and that R23 was involved in a motor vehicle accident, the note indicates R23 sustained minor injuries and will not be admitted. Nursing note 2/22/11 6:00am indicates that R23 will be admitted to the hospital diagnosis of right knee fracture. According to social service note dated 2/22/11 indicates that R23 was admitted to the hospital last night, after being hit by a car. The note indicates that nursing staff was informed that R23 was brought to the hospital by the local police department. On 4/15/11 at 1:00pm E3 (Director of Nurisng),
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 41 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 41 said that she was notified at home the evenin of 2/21/11 by the facility nursing staff that R23 had eloped from the facility and was involved in a motor vehicle accident, and sustained a fracture to the right lower extremity. According to the facilty's sign in/ sign out log for 2/17/11 and 2/21/11 R23 had not signed out of the facility. On 4/15/11 at 3:30pm E24 (receptionist / security), said that she worked the front desk on the evening of both 2/17/11, and 2/21/11. E24 said that she don't recall R23 leaving the facility, and don't recall R23 signing out of the facility during her shift. During observation of the facility front door, there was (2) sets of double doors noted, the inside double door on the left hand side was controlled electronically, and the right sided door opened when pushed. The door on the right side didn't lock and was observed throughout the course of the survey not to lock from the inside. On 4/15/11 at 3:45pm E9 (administrator) said that the right side door wouldn't lock because it would be a fire hazard, E9 said that she had documentation from OSHA. E9 was unable to provide survey team with OSHA documentation. According to the facility's elopement denotes that the facility shall identify potential safety hazards as part of its quality assurance program and address these issues as warranted. The policy also denotes an assessment addressing the individual's potential for elopement or unauthorized departure shall be performed in accordance with the facility's documented policy.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 42 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 42 Residents identified as being at risk shall have care plans in place describing prevention strategies which may include behavior strategies and supervision. Residents identified as being at risk should only leave the facility when accompanied by a responsible individual. According to the facility's 24 hour front desk security policy and procedure denotes under no circumstance is the front desk left attended at any time. Keep front door locked at all times residents, are to be buzzed in. The policy also indicates that the front desk security person will monitor all residents sign in /sign out, checking all residents pass privilege level prior to allowing residents to sign out. Every resident must sign in and out every time they leave the facility. The policy also denotes residents identified as being at risk should only leave the facility when accompanied by responsible individual. The policy denotes any resident that is observed eloping from the facility, the front desk personal on duty is to immediately announce Code Yellow, via the intercom system. The immediate Jeopardy was removed on April 19, 2011 at 2:00pm. E3 (Director of Nursing) was notified via telephone conference. However the facility remains out of compliance at a scope and severity level 2 because of the need to allow for the facility to complete staff in-services, and to evaluate the effectiveness of the abatement plan for F323. The facility submitted the following plan: 1). Revision of the Elopement Policy by Administration, Social Services Director, Social
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 43 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 43 Work Consultant, and Director of Nursing to more concretely and explicitly detail facility response to residents with elopement or wandering behaviors 2). Every resident's elopement assessment will be reviewed by the social service department quarterly and updated as needed, per behavioral or elopement incident. New assessments will completed if necessary, the social service director will oversee assessments reviews and updates. 3). Every resident's elopement care plan will be reviewed quarterly, or as needed per behavioral or elopement incident by the social service department, and the Social Service Director will oversee care plans reviews and updates. The social service consultant, David Beard, LCSW will audit care plans quarterly and on as needed basis. 4). The elopement policy has been reviewed and updated to reflect current practices including Code Yellow procedure, Front desk tracking forms, elopement list and Identified offender elopement procedure. 5). All residents will reassessed by the social service department, using the community survival risk assessment and the elopement risk assessment to identify residents with increased risk of coming to harm in the community and those with elopement behavioral issues. The Social service director will oversee the reassessment of residents. 6). Residents having a substantial risk of coming to harm in the community or serious elopement
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 44 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 44 behavior issues will be care planned appropriately by the social service department. Updated care plans have been filed in residents charts and will be revised / updated quarterly or as needed by the Social service department / Social Service Director. The consultant David Beard, LCSW, will audit care plans quarterly or on as needed basis. 7). A list of resident "At Risk" of elopement or wandering behaviors will be updated weekly by the social service case worker and distributed to front desk personnel, Administration, and all department heads. Social Service Director will follow up behind the social service case worker to ensure communication between all staff is being implemented regarding the "At Risk" elopement list. A weekly updated copy of the elopement list will remain at the front desk at all times. 8). Any identified offender that leaves the facility unauthorized will immediately reported to law enforcement. All of the above actions have initiated and will be completed by April 22,2011. Quality Assurance 1). LCSW consultant David Beard, Administrator, and Social Service Director have conducted an in-service with front desk staff and department heads to review the new elopement policy: including code yellow procedures and tracking starting 4/13/2011 will be completed by 4/22/2011 and on-going.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 45 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 45 2). Elopement incident have been and will continue to be reviewed by all the Department Heads and Administration with the goal of improving the elopement policy to minimize potential for harm and improve therapeutic outcomes. Weekly "Risk management " meetings with all department heads will review Code Yellow tracking data to address any elopement issues, along with QA meetings beginning Monday April 25th, 2011, and quarterly there after. 3). Pass privileges level have been reviewed by the social service department for all residents and will continue to be reviewed on a quarterly, or as needed (per behavioral or elopement incidents) in accordance with the pass privilege policy. The review began on April 13, 2011 and is on-going. 4). All residents care plans will be reassessed by the social service staff for additional changes to their community survival or elopement risk assessments quarterly, or as needed per behavioral or elopement incident. The Social Service Director will audit assessments per incident, and / or annually on the MDS starting 4/13/2011 and on-going. 5). All residents care plans for elopement risk have been and will continue to be reevaluated by the inter-disciplinary team at their quarterly meeting, or more frequently as deemed appropriate by the inter-disciplinary team starting 4/13/2011 and on-going. 6). In-service for new Code Yellow tracking form in addition to elopement screening intervention,
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 46 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 46 and procedure when following an elopement per new policy. 7). Physical security measures will be increased. A section of the lobby partition will be removed to allow for a wider passage and easier access to the front door. Additional security personnel will be hired for front door observation, daily from 7:00am to 11:00pm. Date of compliance 4/22/2011 and on-going. 8). Updated elopement policy and code yellow tracking form and employee front desk relief form are attached. 9). Those residents signing out on pass for longer than their pass privilege allows are to sign in and out in both the nurses station and at the front desk. 10).The pass privilege levels are updated by the social service department and given to the front desk for reference. All front desk personnel are to document the current pass level for every individual resident when signing in or out. The signature of employee doing so, is also required on the Residents sign in / out sheet. The Social Service Director will audit the sign in / out sheets ensure pass levels are being interpreted correctly and efficiently by front desk staff on a weekly basis.

F 323

B.) R10 was admitted to the facility on 7/14/10 with diagnosis of Bipolar Disorder and Depression. Per Illinois State police Criminal Background
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 47 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 47 Check initiated on 7/16/10, R10 is an identified offender and a registered child sex offender. Review of the criminal history data for R10 indicated that he is registered as a child sex offender, and was also imprisoned for attempted rape and burglary. The Illinois Sex Offender Online Search verified that police report and further indicated that he was convicted as a child sex offender, convicted for rape, and aggravated sexual abuse of a victim <13 years old. Review of R10's nurses notes indicated that he was also involved in the following aggressive behaviors and altercations with other residents in the facility : a) 10/12/10 at 10:30 AM, R10 reported that another resident hit him and he sustained a black eye. b) 10/28/10 6:30 PM, hit another resident, was verbally aggressive to staff. c) 11/23/10 at 10 AM - yelling and screaming at staff and threw chairs. d) 12/20/10 at 10:30 AM - hit another resident stating he did so because the other resident laughed at him and killed his 2 friends. e) 1/31/11 at 2 PM - agitated at staff and other residents. f) 3/12/11 at 5:40 PM - was hit on one side of the face and was bleeding.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 48 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 48 Furthermore, R10 is also not safe unsupervised as he had histories of falls per nurses notes on 11/29/10, 12/9/10, and 2/10/11. On 11/29/10 at 5 PM, R10 slipped off a chair and fell on his side. On 12/9/10 at 6 AM, he was found laying on the floor with a hematoma on his forehead per nurses notes. On 2/10/11, R10's nurses notes indicated he also fell while on his outside program. There was no indication in his care plan and record that the facility put in place interventions to prevent him from falling further nor was there evidence that an assessment to determine cause of falls was done. This was verified by E4 ( Asst. Director of Nursing ) during 4/7/11 interview at 1:40 PM that R10's care plan was not showing any intervention each time R10 fell. E4 also was not able to show evidence that there was an assessment for each fall to determine cause of falling, that way, appropriate intervention can be put in place. R10's nurses notes dated 3/4/11 indicated that at 2 PM, R10 stated that he was leaving the facility after putting his personal belongings inside a garbage bag. This nurses notes indicated that this resident was told he was back home and that, the facility is not the hospital that R10 thought discharged him already.

F 323

When E3 ( Director of Nursing ) was interviewed on 4/7/11 at 2:25 PM, E3 said that on 3/4/11 R10 went to the nurses station after lunch time, and verbalized that he wanted to leave the facility. E3 said that she called the front desk security and told security to watch out for R10. E3 said that later, they couldn't find him and no staff saw him leave.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 49 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 49 When E21 ( security ) was interviewed on 4/7/11 at 1:50 PM, E21 said that on 3/4/11, just after he came back from his break, E3 asked him if he saw R10 because R10 couldn't be located in the building. E21 said that he just overheard afterwards that R10 got out of the building and took a bus. E21 said he did not see R10 leave the door, and that, if R10 left through the exit door, it would have triggered a light in the front desk that the exit door was opened, but it did not. Per above 4/7/11 interview at 2:25 PM, E3 confirmed that no staff saw R3 leave the building. E3 said that one resident saw R10 get to the bus. Per observation on 4/8/11 at 12:10 AM, the front door won't open unless the switch on the wall by the front desk is flipped. Per observation, there is a high school at the corner across the facility, less than 500 feet away from the front door of the facility. Per Community Survival Skills Assessment dated 2/19/11, R10 is not capable of unsupervised outside pass privileges due to continued delusional and disorganized thought processes. On 4/8/11, the facility finally found out where R10 was, when a hospital called that R10 wanted to come back to the facility. 3) R16 was admitted to the facility on 8/31/10 with diagnosis of Paranoid Schizophrenia. Per nurses notes, R16 eloped from the facility on the following dates :
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 50 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 50 a) 10/27/10 - eloped from facility b) 11/8/10 850 AM - eloped from the facility by walking out of the door. Staff went outside to look for him but R16 was long gone by then. Returned to facility at 8:30 PM. c) 11/9/10 3:45 AM - eloped by pushing the front door open and continued to just walk away from the building. At 7:45 AM, R16's sister said that R16 is not with her. At 8:55 AM, back to the facility handcuffed by the police , and sent to the hospital. d) 11/26/10 went outside of the facility without shoes, socks, or coat. Staff chased him back and was sent to the hospital. 11/26/10 hospital History and Physical indicated that at the facility, R16 was confused, delusional, disinhibited, and run out of the facility in freezing cold weather without coat and shoes. e) 12/12/10 2:30 AM - pushed open the front door and left. Per nurses notes dated 12/12/10, R16 told the guard he was leaving but he will be back. The guard went out of the door to look for him but was gone already. No indication why the guard allowed him to leave in the first place. Returned at 8:30 AM of 12/12/10. f) 12/19/10 5 PM - witnessed by staff as had left without signing out. Returned at 2:10 AM the next day. Per incident report of the same date, R16 run out of the facility. g) 12/29/10 5 PM - cannot be located in the building. returned at 12/30/10. h) 1/1/11 2:15 AM - Observed by security putting a chair up to the fence and climbing over fence. Staff called him but ignored staff and left. i) 2/26/11 9:15 AM - walked out of the facility and returned at 2:30 PM.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 51 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 51 R16's Social Service Quarterly Report dated 10/24/10 also indicated that he had one episode of attempting to jump over the fence on 8/25/10. Review of R16's Social service Quarterly note dated 1/24/11 showed that R16 has a pass privilege of Level One. During daily status on 4/7/11, E5 ( Social Service Director ) said that a Level One Pass Privilege means the residents cannot leave the facility without staff or family supervision outside. According to R16's Community survival Skills Assessments dated 11/19/11 and 2/19/11, R16 is not capable of unsupervised pass privileges at the time of assessment. R16's Community Survival Skills Assessment dated 2/19/11 indicated R16 follows rules addressing participation in his treatment plan, has the ability to adhere to pass privilege policies, and has knowledge of potentially dangerous situations. these were all coded as YES in the assessment eventhough, R16 does not follow nor even attend his treatment plans, eventhough he doesn't adhere to pass privilege policy as shown above in the elopement examples, and even though he had even an episode of running outside the facility not dressed appropriately for the freezing cold outside on 11/26/10. Review of R16's care plan for elopement showed no indication of what interventions the facility put in place each time R16 leaves the facility unauthorized and unsupervised. Per E5 during 4/7/11 Daily Status Meeting, the
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 52 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 52 facility is not able prevent R16 from leaving the facility to visit his family. On 4/8/11, instead of addressing R16's noncompliance with Level Pass restriction, the facility presented a care plan that R16's restriction will be changed to a less restrictive pass restriction at level 2, as the facility is not able to prevent R16 from leaving the building unsupervised. 4) R3 has a diagnosis of Tardive Dyskinesia. Per nurses notes dated 3/16/11, R3 fell backwards while in the hallway. On 3/9/11, R3 also fell in the Horizon Room and sustained abrasion in the coccyx. R3's care plan for falls presented on 4/7/11 showed no indication that it was revised each time he fell. Review of fall risk assessment showed no indication that the facility is assessing what really caused R3 to fall and put in place interventions appropriate and related to the fall so R3 does not fall again. During 4/7/11 interview with E23 ( care plan nurse ), E23 was not able to explain what caused R3 to fall on 3/6/11 and 3/9/11. E23 was also not able to explain why there was no goal in R3's fall care plan nor why there were no new interventions each time R3 falls. She added that although it is not found in the care plan, R3 should be assisted by staff if his gait becomes unsteady. When asked how the direct care staff like the nurses aide will know that if it is not in the care plan, E23 did not respond. 5) During initial tour on 4/5/11 with E10 ( Medical
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 53 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 53 Record/ CNA ) which started at 9:46 AM, there is : a) a lamp shade with a missing bulb in room 1 of building 33 b) Air conditioner placed on top on a table in room 2 of building 33 c) a lamp shade with a missing light bulb in room 3 of building 15

F 323

C.) Record review of R14 ' s care plan notes dated 10-12-10; R14 was involved with another peer that was verbal and physical. Goals/objectives for R14 to participate with the conflict resolution group that meets in-house once a week and stress management group once a week. Record review of care plan dated 12-10-10; R14 was involved in an incident where he punched his peer in the nose. Approaches/intervention; resident will be prompted to attend stress management group and conflict resolution group. Both meet once a week. Record review of care plan dated 1-19-11; R14 accused a peer of wearing his shirt and attempted to remove it off his peer. During incident R14 grabbed the peer by the neck and shirt. Approaches/interventions continue to prompt resident to maintain his attendance in conflict resolution group and stress management group; meet in each group once a week. Interview with E5 (Psychiatric Rehabilitation Services Director) at 2:48 PM on 4-7-11 states
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 54 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 54 after R14 ' s incidents care plan should have been updated. Interview with E6 (Psychiatric Rehabilitation Services Counselor) on 4-8-11 at 9:30 AM states he did not know that R14 was already in conflict resolution after the incident on 12-10-10. E6 states he did not change any interventions from the incident in 1-19-11; just continued the same interventions stress management and conflict resolution. E6 states he should have prepared a care plan with added interventions after the 2-13-11 incident. E6 states he kept R14 in the same programs and adding different interventions should have been tried. Record review of the social service incident dated 2-13-11, R14 physically attacked another resident because that particular person grabbed his soft drink. D). During the initial tour on 4-5-11 at 9:45 am, accompanied by E 3(Director of Nursing), the following were observed: 1. Room 21-04- bathroom tub without anti slip strips. 2. Room 21-05- 1 light fixture below cabinets, no cover, no bulb, bathroom, 1 towel rack prong tip is jagged. 3. Room 21-06- light fixture below cabinet, no cover, 1 missing bulb. 4. Room 21-10-1 privacy curtain ceiling bar frame loose from the ceiling. During the environmental tour on 4-7-11 at 10:45 am, accompanied by E 14(Maintenance), the following were observed: 1. Basement Stair Well-1 ceiling speaker system noted junction box not covered with exposed
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 55 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 55 wiring. 2. Boiler Room- chemical cleaning agents located on cabinet. 3. Hallway next to room 15-12- 1 cracked window. 4. Room 07-06- bathroom windows cracked, room ceiling light bulb cover cracked and not secured. On 4-7-11 at 4:30pm during the daily status meeting, the facility was notified of the concerns. During the initial tour of the facility on 4/5/11 that began at 9:45 AM, it was observed in room 8 building 7 that broken light bulb pieces were scattered on the floor. R9 stated to E4 (assistant director of nursing) at that time that he had broken the bulb in an attempt to remove the bulb from the bedside lamp. In room 9 in building 7 during the tour it was also observed that a 8 ounce bottle of rubbing alcohol was sitting on a bedside table and an electric iron was in the cabinet. E4 stated when interviewed at this time that R9 should be supervised more closely because he has many adverse behaviors. In addition, E4 stated that the facility does have residents that wander throughout the facility going into other residents rooms and that the bottle of alcohol should not be at any residents bedside. E4 further stated that he was not aware of any resident that is allow to iron in their rooms and that the iron would be removed from the cabinet.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 56 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 323 Continued From page 56 On 4/6/11 at 1:00 PM, and 4/7/11 at 2:00 PM, R17 was observed in the smoking in courtyard. R17 was futher observed on both occasions yelling, using foul language, with aggressive behavior toward other residents in the courtyard. E3 (director of nursing) stated when interviewed on 4/7/11 at 4:00 PM, that the courtyard is open 24 hours and that it is only supervised by staff during the planned smoking

F 323

Surveyor: Tillman, Delores F 325 483.25(i) MAINTAIN NUTRITION STATUS SS=G UNLESS UNAVOIDABLE Based on a resident's comprehensive assessment, the facility must ensure that a resident (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; and (2) Receives a therapeutic diet when there is a nutritional problem.

F 325

6/24/11

This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that significant weight loss for 4 sampled residents ( R3, R4, R10 ) were addressed by the facility in the
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 57 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 325 Continued From page 57 sample of 24. The facility also failed to consistently obtain monthly weights for 3 sampled residents ( R3, 10 and 11). As a result of this failure, R3 continued to lose weight ( 28 % in 6 months ) in the month of March 2011. Findings include : 1) R3 has diagnoses of Schizophrenia, Depression, History of Alcohol Abuse, Hypertension, Hyperlipidemia, and Gastroesophageal Reflux Disease. R3 was originally admitted to the facility on 2/15/11. The following were R3's monthly weight records reflected on the monthly weight sheet : a) April 2010 = 154.2 lbs b) May 2010 = 152 lbs c) June 2010 = 153 lbs d) July 2010 = 147 lbs e) August 2010 = 144.2 lbs f) September 2010 = 146.6 lbs g) October 2010 = blank h) November 2010 = 111.2 lbs i ) December 2010 = 109.6 lbs j) January 2011 = 107.4 k) February 2011 = 107.4 lbs l) March 2011 = 104.6 lbs Review of the above records indicated that for the month of October 2010, R3's record showed no indication that his weight was obtained, nor was there any explanation why it wasn't. In the absence of the October 2010 weight, it cannot be determined when R3 started losing a lot of
FORM CMS-2567(02-99) Previous Versions Obsolete

F 325

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 58 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 325 Continued From page 58 weight. In November 2010, R3's weight was at its lowest at 111.2 lbs., since April 2010. R3 also sustained a significant weight loss of 25.2 % in 3 months from September 2010 to December 2010. Review of R3's record showed no indication that this significant weight loss was assessed, addressed, and referred to the physician or dietician, to determine cause of continued weight decline, and prevent further weight loss. This was also a 28 % significant weight loss in 6 months. Similarly, in February 2011, R3 also sustained a 25.8 % significant weight loss in 3 months from August 2011 and a 28 % significant weight loss in 6 months, from September 2010 to March 2011. Per R3's Dietary notes, there was no assessment by the dietician for R3's February 2011 and March 2011's significant weight losses. Although E11 ( Food Service Supervisor did some sort of assessment on R3's February weight loss, it does not mention any weight decline, nor determine possible cause of continued significant weight decline, nor mention referral to the dietician, nor was there evidence of any interventions to address these weight losses. During 4/6/11 interview with Z3 at 9:50 AM, Z3 said that she works with what the facility gives her. Z3 said that she calculates the weight changes based on the current weight and the previous month's weight the facility gives her. There was no indication why Z3 was not able to do assessment and address the weights on December 2010, February 2011 and March 2011. Z3 also said that previously prior to E3 ( Director of Nursing ), she was only given the
FORM CMS-2567(02-99) Previous Versions Obsolete

F 325

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 59 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 325 Continued From page 59 current month's weight by the dietary department, when Z3 comes to the facility. According to E3 during 4/8/11 interview at 3 PM, previously it was the dietary department's responsibility to handle the weights, but that E3 said she had to take over recently. Review of facility's Weights Policy indicated that monthly weights will be obtained on the 5th day of the month, documented on the resident's monthly vital sign sheet. It also indicated that residents with 5 % weight loss/gain in 30 days and any resident with a 10 % weight loss or gain in 6 mths will be identified as at high risk, referred to the dietician for evaluation, and any dietician recommendation will be forwarded to nursing and physician. During observation on 4/8/11 at 11:30 AM, R3 was observed as thin and emaciated. 2) R10 was admitted to the facility on 7/4/10 with diagnoses of Diabetes mellitus, Hypertension, and Depression. R10's monthly weight record for October 2010 showed that he weighed 199 lbs. This was a significant weight loss of 8.2 % from July 2010 weight of 217 lbs.. Review of R3's Dietary Progress Notes however indicated that although Z3 assessed him in October 2010, Z3 was using a different weight of 210 lbs, and not the 199 lbs in R3's chart. As a result, per Z3's assessment, R10 did not sustain a significant weight loss. There was no indication of any recommendation to address
FORM CMS-2567(02-99) Previous Versions Obsolete

F 325

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 60 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 325 Continued From page 60 R10's weight loss for this month. During interview on 4/6/11 at 9:50 AM, Z3 said that she does not know why she used 210 lbs for R3's assessment in October 2010, but that she said she only uses what is given to her on a monthly basis. 3) R11 was admitted to the facility on 7/21/10 with diagnoses of Anemia, Arrythmia, and Schizophrenia. Review of R11's monthly weight record showed that the August and September 2010 weights were blank. There was no indication why R11's weight wasn't taken or recorded. R4 was admitted in October 2008 and weighed 193 pounds (lbs) with height of 5 feet 11 inches. The weight record documented the following weights: July 2010 - 179.6 lbs. (pounds) August 2010 - 174 lbs September 2010 - 170.2 lbs October 2010 - 171.2 lbs November 2010 - 171.8 lbs December 2010 - 168.8 lbs January 2011 - refused February 2011 - 146.2 lbs March 2011 - 155 lbs April 2011 - 154 lbs (per E 12 (Dietitian) on 4/6/11) R4 had insidious weight loss of 39 lbs. since admission. R4 had a significant weight lost of 10 % in 6 months. The plan of care initiated on 10/7/10 was not individualized and was not updated. The nutritional progress notes indicated
FORM CMS-2567(02-99) Previous Versions Obsolete

F 325

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 61 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 325 Continued From page 61 that E11 (Food Service Manager) evaluated the condition on 10/7/10 and 1/25/11 was countersigned by E 12 on 10/12/10 and 2/7/11 respectively. On 2/7/11, E 12 documented the weight to be 146 lbs with a 16 lbs weight loss in one month. There were no lab values. The plan was to follow-up as needed. The nurses' notes indicated the physician was only notified of the weight loss on 4/5/11. The Dietary Recommendation dated 4/6/11 documented as recommendation: No supplement justified at this time. BMI (Basal metabolic index) above 18 . Wt (Weight) has not changed significantly past 2 months. On 4/6/11 at 9:50 AM, E 12 stated that R4 did not visibly appear to have weight loss. E 12 stated that R4's current weight was 154 lbs. E 12 stated there was no explanation why the resident was losing weight and that the nursing staff would notify the physician if the resident was losing weight. E 12 stated that the Food Service Director and the Assistant Director of Nursing should be the ones updating the care plan.

F 325

. F 329 483.25(l) DRUG REGIMEN IS FREE FROM SS=E UNNECESSARY DRUGS Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose
FORM CMS-2567(02-99) Previous Versions Obsolete

F 329

6/24/11

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 62 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 329 Continued From page 62 should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

F 329

This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide a documented clinical rationale for gradual dose reduction (GDR) for 6 of 24 residents in the sample (R4,R8, R12, R13, R19, R20), and failed to ensure that 1 resident receiving the medication Ambien, had appropriations for use involving 1 of 24 sampled residents (R 6).

Findings include: 1) R4 was admitted on 10/15/08 and has the diagnoses which includes Paranoid Schizophrenia. Z1 (Pharmacist) wrote a pharmacy form (Note To Attending Physician/Prescriber) dated 8/4/10 to Z4
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 63 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 329 Continued From page 63 (Psychiatrist) explaining that R4 was on Zyprexa 15 mg.(milligrams) daily and periodic dosage reduction was recommended. There was no documented response on the form or on the physician progress notes from Z1. 2) R12 has the diagnosis of Paranoid Schizophrenia and was on Fazaclo 50 mg po (by mouth) twice daily. Z1 wrote a pharmacy form (Note To Attending Physician/Prescriber) dated 3/9/11 requesting to evaluate the current regimen to determine if a reduction could be attempted. There was a physician signature dated 3/15/11 on the form but there was no documentation whether the dosage should remain the same or if it can be reduced. 3) R13 was admitted in January 2009 has the diagnoses which includes Depression and History of Bipolar Disorder with Psychotic Features. The April 2011 Physician's Order Sheet (POS) documented that R13 was prescribed Sertraline 50 mg po daily and Abilify 15 mg po daily. Both medications were started on 1/13/09. There was no documentation found addressing GDR. 4) a) R19 was re-admitted to the facility on 1/14/11 has the diagnoses which includes Schizoaffective Disorder and Depression. The April 2011 POS documented that the sedative Zolpidem 10 mg po at bedtime was started on 1/14/11. The Medication Administration Record (MAR) for February 2011 and March 2011 indicated Zolpidem was given every night. There was no psychotropic consent form for this medication found. E3 (Director of Nursing ) was informed of this and was not able to provide the
FORM CMS-2567(02-99) Previous Versions Obsolete

F 329

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 64 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 329 Continued From page 64 consent. The April 2011 POS documented an order on 4/6/11 to discontinue the Zolpidem (Ambien). The April 2011 MAR indicated that it was given through 4/7/11. There was no documentation found for indication of this medication. There was also no documentation why it was abruptly discontinued. Z1(Pharmacist) wrote a note (Note to Attending Physician /Prescriber) dated 2/8/11 recommending dosage reduction of Ambien to 5 mg at bedtime. There was no documented response from Z4 (Psychiatrist). R19 was observed on the initial tour on 4/5/11 sleeping in her bed and randomly throughout the day. On 4/6/11 at 10:00 AM resident was in bed asleep snoring loudly. On 4/7/11 at 11:35 AM, E8 (Psychosocial Rehab Counselor) stated that R19 only come to groups sporadically and spends most of the time in her room. b) The April 2011 POS indicated orders for Ativan 2 mg po (oral) or IM (intramuscularly) every 6 hours as needed. There was no psychotropic consent found for the Ativan po or IM also. On the February 2011 MAR, it indicated that Ativan 2 mg IM was administered on 2/5/11. However, in the back of the MAR, it was signed out that Haldol 1 mg IM was administered. On 4/8/11 at 4:10 PM, E22 (Nurse) clarified that she administered Ativan 2 mg IM and not Haldol. c) Z1 (Pharmacist) wrote a note to Z4 (Psychiatrist) dated 8/12/10 to evaluate the Depakote and Seroquel if reduction could be attempted. There was no documented response from Z4. Z1 wrote notes to Z4 dated 10/8/10 and 1/5/11 to review the Haldol IM/PO since they are viewed
FORM CMS-2567(02-99) Previous Versions Obsolete

F 329

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 65 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 329 Continued From page 65 as chemical restraints. There was no documented response from Z4 on both requests. 5) R20 has multiple diagnoses including Paranoid Schizophrenia. Z1 (Pharmacist) wrote a note dated 12/6/10 to Z4 (Psychiatrist) to evaluate the Risperdal 1 mg every morning, Depakene 750 mg twice daily, and Risperdal 4 mg at bedtime. There was no documented response from Z4 found. The April 2011 POS indicated the resident was still receiving the same dosages for the same medications. In the above pharmacy reviews, Z1 documented on the note to the physician that, "If you determine a reduction could not be tolerated, please DOCUMENT in your progress notes or below why any additional attempted dose reduction is likely to impair the resident's function or increase distressed behavior, so the facility may remain compliant with regulations?" The facility policy on Gradual Dose Reduction documented: "If the psychiatrist has decided not to decrease the dose or discontinue the psychotropic medication an explanation should be evident on his response sheet sent by our pharmacy consultant." R1 is a 59 year old male with diagnoses that include Schizophrenia, Paranoid, and Metal Retardation. R1 was admitted to the facility on 5/7/10. The initial MDS (minimum data set) documents that R1 is mildly cognitively impaired and has poor decision making skills. R1, per the physician order sheet dated 4/1/11
FORM CMS-2567(02-99) Previous Versions Obsolete

F 329

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 66 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 329 Continued From page 66 includes instructions for the following medications: Lamotrigine 150mg each morning and night, Clonazepam 0.5mg every 12 hours, Seroquel 800mg at bedtime, Benztropine 1 mg, at bedtime, and Zyprexa 30mg at bedtime. There was no documentation by the physician or nursing in the clinical record indicating that a drug reduction plan had been attempted for R1. The pharmacy recommendation for drug reduction for 7/2010 to 2/2011 were not signed/reviewed by the physician. Z1 (pharmacy) stated when interviewed on 4/8/11 at 3:30 PM, that he had made a written recommendation to the facility in 11/2010 and 1/2011 that R1's Zyprexa be reduce to 20mg. E3 (director of nursing) stated in an interview on 4/8/11 at 4:00 PM, that the recommendations that are made by the pharmacy are placed in the physicians mailboxes for the physician's review. E3 also stated that once the pharmacy recommendation's are reviewed by the attending physician, the physician should sign the pharmacy form and return the form to the director of nursing.

F 329

R6 is a 63 year old resident admitted with diagnosis which includes Seizures, Depression, Anxiety, and Hypertension. Review of the POS(Physician Orders Sheet) dated April 2011 indicates that resident receives Ambien 10 milligrams take 1 every hours sleep as needed. The start date is 10-20-10. Review of the physician progress notes, nurses notes, POS, psychiatrist progress notes, and care plans does
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 67 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 329 Continued From page 67 not provide documentation related to the use of the medication. Ambien is classified as a Hypnotic, used as a short term treatment of insomnia. Interview with E 3(Director of Nursing) on 4-7-11 at 2:30pm stated that the physician orders was written on 10-20-10

F 329

R1 is a 59 year old male with diagnoses that include Schizophrenia, Paranoid, and Metal Retardation. R1 was admitted to the facility on 5/7/10. The initial MDS (minimum data set) documents that R1 is mildly cognitively impaired and has poor decision making skills. R1, per the physician order sheet dated 4/1/11 includes instructions for the following medications: Lamotrigine 150mg each morning and night, Clonazepam 0.5mg every 12 hours, Seroquel 800mg at bedtime, Benztropine 1 mg, at bedtime, and Zyprexa 30mg at bedtime. There was no documentation by the physician or nursing in the clinical record indicating that a drug reduction plan had been attempted for R1. The pharmacy recommendation for drug reduction for 7/2010 to 2/2011 were not signed/reviewed by the physician. Z1 (pharmacy) stated when interviewed on 4/8/11 at 3:30 PM, that he had made a written recommendation to the facility in 11/2010 and 1/2011 that R1's Zyprexa be reduce to 20mg. E3 (director of nursing) stated in an interview on 4/8/11 at 4:00 PM, that the recommendations that are made by the pharmacy are placed in the
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 68 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 329 Continued From page 68 physicians mailboxes for the physician's review. E3 also stated that once the pharmacy recommendation's are reviewed by the attending physician, the physician should sign the pharmacy form and return the form to the director of nursing. F 334 483.25(n) INFLUENZA AND PNEUMOCOCCAL SS=D IMMUNIZATIONS The facility must develop policies and procedures that ensure that -(i) Before offering the influenza immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. The facility must develop policies and procedures that ensure that -FORM CMS-2567(02-99) Previous Versions Obsolete

F 329

F 334

6/24/11

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 69 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 334 Continued From page 69 (i) Before offering the pneumococcal immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and (iv) The resident's medical record includes documentation that indicated, at a minimum, the following: (A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. (v) As an alternative, based on an assessment and practitioner recommendation, a second pneumococcal immunization may be given after 5 years following the first pneumococcal immunization, unless medically contraindicated or the resident or the resident's legal representative refuses the second immunization.

F 334

This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure that the pneumococcal vaccine
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 70 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 334 Continued From page 70 was offered and failed to provide tracking of the administration or refusal for 5 of 24 sampled residents (R1, R2, R3, R4, and R5). Findings include: According to the review of R1, R2, R3, R4, and R5's clinical record no evidence of the administration of the pneumococcal vaccine was offered to the above mentioned residents. A review of all 5 clinical records provide no evidence of an informed consent or education provided for the pneumococcal vaccine was provide to the 5 mentioned residents. A review of the medication administration record, nurses notes, vaccination record, and physician orders sheet no documentation noted. According to the immunization and vaccination policy denotes all residents will receive immunizations and vaccinations that help in preventing infectious disease, unless medically contraindicated or otherwise ordered by the physician. The policy also includes staff to document residents refusal and notification of the physician, nursing to document per policy and procedure. The policy also indicates that the vaccine will be administered during the flu season when available to the facility. The policy also denotes at any time a resident refuses, the resident will be counseled the reason of importance for the vaccination is of their well being. If resident still refuses documentation is required in the nurses notes. E3 provided survey team with a residents influenza and pneumococcal vaccination log, the pneumococcal portion for the log was blank.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 334

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 71 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 334 Continued From page 71 On 4/13/11 during the daily status meeting E3 (director of nursing), said that she was new to the facility and that the old director of nursing left without a tracking system for pneumococcal vaccine for the residents in the facility. E3 said that she is in the process of putting a influenza and pneumococcal system in place by the next flu season. 1) R4 is a 52 year-old with diagnoses of Paranoid Schizophrenia, Marijuana Abuse and Hypertension. The Influenza and Pneumococcal Vaccination Log provided by the facility documented that R4 received the flu vaccine on 12/21/10. There was no documentation for the pneumococcal vaccine. There was no consent forms found for the influenza and pneumococcal vaccinations. 2) R12 is a 49 year-old with diagnoses of Paranoid Schizophrenia, Hepatitis C and Seizure Disorder. The Influenza and Pneumococcal Vaccination Log provided by the facility documented that R12 received the flu vaccine on 12/21/10. There was no documentation for the pneumococcal vaccine. There was no consent forms found for the influenza and pneumococcal vaccinations. 3) R19 is a 27 year-old with diagnoses of Schizoaffective Disorder, Depression and Uterine Bleeding. There was no documentation found that R19 received any vaccination. There was no consent found in the clinical records. On 4/7/11 at 11:15 AM, the immunization consent forms were requested from E4 (Assistant
FORM CMS-2567(02-99) Previous Versions Obsolete

F 334

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 72 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 334 Continued From page 72 Director of Nursing). E4 was observed going through the charts and the binder where the consents were kept. E4 stated he was not able to find the consents for the above residents. R 2 is a 82 year old resident admitted to the facility with medical diagnosis which includes Bipolar Disorder, Paranoid Schizophrenia, Anemia, and Dementia. POS(Physician Orders Sheet) dated December of 2010 indicates that R 2 received the Influenza immunization on 12-21-10. There is no documentation regarding education provided prior to receiving the immunization. On 4-6-11 at 4:30pm, during the daily status meeting, the facility was informed of the concerns. F 367 483.35(e) THERAPEUTIC DIET PRESCRIBED SS=D BY PHYSICIAN Therapeutic diets must be prescribed by the attending physician.

F 334

F 367

6/24/11

This REQUIREMENT is not met as evidenced by: Based on record review and interview facility failed to follow the dietician ' s recommended ulcer diet for 1 (R14) of 14 residents in a sample of 24. Findings include: Record review of R14 ' s quarterly nutritional assessment from E12 (Dietician Consultant) on 3-15-11 denotes ulcer diet recommended. Record review of R14 ' s diet change order card dated 1-15-11 denotes regular diet. Record review of R14 ' s food card denotes low sodium diet. Interview with E11 (Food Supervisor) at 9:15 AM
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 73 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 367 Continued From page 73 on 4-6-11 states today is the first time she has seen the recommendation for ulcer diet. E11 states nursing should have sent her the pink diet change form. E11 states she did not receive the diet change order from nursing. Interview with E12 (Dietician Consultant) at 9:37 AM on 4-6-11 states when she makes the recommendations, the doctor is to be informed before the diet is modified. E12 states after doctor is informed, R14 ' s food card should have the recommended modifications written on them. Record review of physician ' s order sheet dated 4-6-11, ulcer diet, no spicy foods, and small frequent meals. F 371 483.35(i) FOOD PROCURE, SS=F STORE/PREPARE/SERVE - SANITARY The facility must (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

F 367

F 371

6/24/11

This REQUIREMENT is not met as evidenced by: Based on observation, interview and policy review, the facility failed to ensure that food items were labeled and dated. Findings include: On 4/5/11 at 9:50 A.M. during the initial tour of the kitchen with E11 (Food Service Manager) the
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 74 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 371 Continued From page 74 following were observed: Dry Storage Room: - 3 bags of crackers - unlabeled, undated - 4 bags of animal crackers - unlabeled, undated - 1 gallon peanut oil - opened, undated - 1 large plastic container with label of chicken soup base, but contained popcorn (unlabeled), undated - 3 large plastic bins unlabeled and undated. Per E11 they contained wheat flour, sugar and rice - 1 plastic bin - unlabeled, undated - E11 stated it was "some kind of meal," then later stated it contained corn meal. - 3 plastic bags of cereals (Cheerios, Rice Krispies, Froot Loops) - opened, unlabeled, undated - bags of disposal plastic eating utensils on the top shelf - opened and exposed - disposable plastic gloves labeled with a name. Per E11 this belonged to a staff. - light bulbs, soft-covered book on the same shelf as food items - 2 - 2 pound bags of Cheerios - removed from original packaging - undated. Walk-in freezer: - 3 bags of frozen items in clear plastic bags removed from the original box - unlabeled, undated. Per E11 they were chicken breasts and turkey fritters. - 8 plastic bags of Italian Blend frozen vegetables - out of the original box, undated - 2 meat items wrapped in plastic- unlabeled, undated - per E11 they were cooked, sliced roast beef. - 1 plastic bag of unknown item - unlabeled, undated - per E11, it was veggie burger.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 371

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 75 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 371 Continued From page 75 - 2 plastic bags cut okra - out of the original box, undated. - 2 unknown items wrapped in plastic - unlabeled, undated -per E11, they were tortillas. - 1 plastic bag of unknown item - unlabeled, undated - per E11 they were chicken tenders - 1 container of frozen broccoli soup - out of the original box, undated. Walk-in-refrigerator: E11 stated this refrigerator was used to thaw meat. - 5 (3 pounds each) chopped spinach, undated, thawed - per E11 it was not going to be served until 4/6/11. - 7 blocks of cheese wrapped in plastic unlabeled, undated - per E11 they were Swiss and American cheese. Walk-in-refrigerator: E11 stated this refrigerator was used to store dairy, bread and staff's food. E11 stated staff did not have a separate refrigerator to store their lunch. - 2 cardboard trays of donuts, one was opened. Both were unlabeled and undated. The facility policy on Storage of Dry Goods/Foods documented: -Foods stored in bins (e.g. flour or sugar) will be removed from original packaging and bins will be labeled with item and date unpacked. -Open products will be labeled and tightly covered to protect against any contamination including from insects and rodents. The facility policy on Storage of Refrigerated Foods documented:
FORM CMS-2567(02-99) Previous Versions Obsolete

F 371

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 76 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 371 Continued From page 76 - Food in the refrigerator will be covered, labeled and dated. F 406 483.45(a) PROVIDE/OBTAIN SPECIALIZED SS=E REHAB SERVICES If specialized rehabilitative services such as, but not limited to, physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and mental retardation, are required in the resident's comprehensive plan of care, the facility must provide the required services; or obtain the required services from an outside resource (in accordance with 483.75(h) of this part) from a provider of specialized rehabilitative services.

F 371

F 406

6/24/11

This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that 8 sampled residents ( R1, R3,R 9,R10, R11, R16, R17, and R18 ) receive psychiatric rehab in the sample of 24. Findings include: a) R18 has diagnoses of Schizoaffective Disorder and Major Depression. Per R18's PAS/MH screen done on 7/9/02, R18 needs psychological rehab and medication monitoring, and that R18 should attend AA meetings. During initial tour on 4/5/11 at 9:46 AM with E10 ( CNA/ Medical record ), R18 was not in the room nor in the facility. Per E10, R18 goes out of
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 77 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 406 Continued From page 77 the facility to see his family everyday. Review of R18's nurses notes indicated that R18 is out of the facility in the following dates: 8/28/10, 9/1/10, 9/8/10, 9/9/10, 9/11/10, 9/18/10, 9/20/10, 12/25/10, 1/5/11, 1/8/11, 1/24/11, 2/4/11, 2/12/11, 3/5/11, 3/26/11, and 4/6/11. According to the facility's psych groups, R18 is not attending any of the groups provided in the facility, despite of indication that R18 had behavioral episodes related to his psych diagnosis. Per Social service notes written by E6 ( case worker ) dated 10/20/10, R18 was hospitalized in August 2010 due to auditory hallucinations. Similarly on 2/16/11 at 4:30 PM, R18 was sent to the hospital with suicidal ideation, and was readmitted back to the facility on 2/23/11 per nurses notes. R18's social service notes do not indicate what the facility put in place to address his psychiatric behavior and diagnosis, and what was put in place to satisfy his recommended psychiatric rehabilitation. During 4/8/11 interview with E6 at 3:49 PM, E6 confirmed that R18 signs out of the facility and visits his sister. E6 also confirmed that R18 does not attend any psychiatric program at this time. 2) R10 was admitted to the facility on 7/14/10 with diagnoses of Bipolar Disorder and Depression. Per state police background check, R10 is also a sex offender. Review of R10's PAS/MH screen dated 12/4/08, R10 requires psychiatric rehabilitation
FORM CMS-2567(02-99) Previous Versions Obsolete

F 406

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 78 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 406 Continued From page 78 services. Per R10's facility social service assessment, R10 is suppose to attend a Human Sexuality Group. Per attendance sheet for the Human Sexuality Group for the month of October 2010, November 2010, and December 2010, there was no indication that R10 had attended the Human Sexuality group for months. For 2011, R10 also did not attend the same group on 1/4/11, 1/18/11, and 2/1/11. When E8 ( Psych rehab aide ) was interviewed on 4/7/11 at 10:40 AM, E8 explained that she started in September 2010 and did not conduct any psych rehab groups until around October or November 2010. E8 said that she did not know that R10 is suppose to attend the Human Sexuality Group until in January 2011, she saw that R10 has a care plan to attend the said group. E8 continued that there was a list of the residents under the specific groups but that she is not sure if R10's name was in the list that time. 3) R16 has diagnosis of Paranoid Schizophrenia and was admitted to the facility of 8/31/10. Per PAS/ MH Level II Notice of Determination dated 9/14/10, the special services to be provided for R16 include the following : a) Mental Health rehabilitation activities b) Illness self -management c) Incentive program to improve participation in treatments d) Community reintegration activities
FORM CMS-2567(02-99) Previous Versions Obsolete

F 406

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 79 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 406 Continued From page 79 During interview on 4/8/11 at 11:30 AM, R16 said that he does not attend any programs or groups in the facility, nor has he talked to any case worker. Review of the in house groups in the facility indicated that R16 attends only 1 group : Medication Compliance group. During 4/8/11 interview with E6 at 3:45 PM, E6 said that originally R16 was under 3 different case workers prior to E6. E6 said that R16 is very stubborn and one cannot have R16 go to attend groups. 4) R3 was admitted to the facility on 2/15/10 with diagnoses of Schizophrenia, Depression, and history of Alcohol Abuse. Review of facility's outside program New Birth Christian Center indicated that R3 attends the outside program every Tuesdays and Wednesdays. However, review of R3's social service notes shows no indication that the outside program is integrated in R3's care. there was no indication what is the purpose of this outside program, the goals for R3, his progress in treating his psychiatric diagnosis. Per E5 ( Social Service Director ) during 4/7/11 interview at 10:55 AM, she just started integrating the outside programs with residents' care. E5 added that the month before, she met the staff from the outside programs. 5) R11 was admitted to the facility on 7/21/10 with diagnosis of Paranoid Schizophrenia.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 406

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 80 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 406 Continued From page 80 Per 1/21/11 Social Service Quarterly Note, R11 is suppose to attend Crime and Consequence group. R11 is an identified offender convicted of battery in 1967. Review of the list of residents in Crime and Consequence group indicated that R11 is not part of the group. Per E6 during 4/7/11 daily report, he just made a mistake that he indicated that R11 should be in that group. b). R1 is a 59 year old male with diagnoses that include Schizophrenia, Paranoid, and Metal Retardation. R1 was admitted to the facility on 5/7/10. The initial MDS (minimum data set) documents that R1 is mildly cognitively impaired and has poor decision making skills. There is no documentation in the social service, nursing or the plan of care indicating that R1 is receiving programming to address his schizophrenia or mental retardation. R9 is a 66 year old male with a diagnosis of Paranoid Schizophrenia. R9 clinical record documents that R9 has been noncompliant with taking medications, refuses programming, to take part in any activities at the facility. The MDS of 2/3/11 and the psychiatry evaluation of 10/20/10 documents that R9 has auditory hallucinations, delusional, and has poor judgement. There was no documented evidence in the clinical record or the facility's program sign-in sheets that indicated that R9 has been attending any programs to address his schizophrenia or medication non-compliance.

F 406

c). R8 is a 58 year old male with diagnoses that


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

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 81 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 406 Continued From page 81 include Blindness, Chronic Depression, and Hypertension. The plan of care dated 2/24/11 failed to document interventions for R8's depression and activities for a blind resident. A review of the facility's programs failed to document that R8 had been attending any programs to assist R8 with his depression. R17 is a 60 year old male with a diagnosis of Schizophrenia-Chronic Paranoid Type. Nursing and social services progress notes document that R17 has aggressive behavior, foul language, and has had many altercations with other residents at the facility. There was no documentation made available by the facility that indicated that R17 has been attending any program to help R17 cope with the above behaviors. E5 (director of social services) stated when interviewed on 4/8/11 at 4:00 PM, that R1, R8, R9, and R17 had been assigned to group programs but had been not been attending the programs. F 431 483.60(b), (d), (e) DRUG RECORDS, SS=D 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 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
FORM CMS-2567(02-99) Previous Versions Obsolete

F 406

F 431

6/24/11

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 82 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 431 Continued From page 82 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 record review, observation & interview, the facility failed to ensure that expired, opened and undated medications were are not available for residents' use for 1 of 24 (R18) sample and four residents outside the sample (R32, R34, R35, R36 ). Findings include: Facility policy "30 day Medication Hold" documents that medication for residents who are discharged from the facility will be maintained at the facility for up to thirty days or until the
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 83 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 431 Continued From page 83 resident is permanently discharged....1. when a resident is discharged, all medications shall be stored in one designated area determined by the facility....6. if the resident has not returned to the facility in 30 days, medications are returned to the pharmacy. An other policy "Expiration Dates-Multidose" documents that when a multidose container is opened, the nurse must document the following on the yellow ancillary sticker or on the actual container: date opened, time opened, expiration date, nurse's initials. During an inspection of the facility's only medication on the first floor with E18 (nurse) the following was observed: in the facility refrigerator, a vial on Novolin 70/30 insulin belonging to R32 had been opened but not dated. A vial of Humulin 70/30 insulin belonging to R33 that had been opened and dated 3/1/11. E18 stated when interviewed at this time, that it is the policy of the facility to date all insulin vials when they are opened and to discard all insulins when they have been open for at least 30 days. The following medications had been opened and not dated: R34-Povidone Iodine 10% solution 8 ounce bottle R18-Fluphenazine Decanoate 25mg/ml 5ml solution R35- Nasoner nasal spray R36-Dorzolamide 2% eye drops Brimonidine 0.2% eye drops Timolol 0.5% eye drops E3 (director of nursing) stated when interviewed on 4/20/11 at 10:30 AM, that all multidose vials, and eye drops should be dated with the date they
FORM CMS-2567(02-99) Previous Versions Obsolete

F 431

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 84 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 431 Continued From page 84 were open this includes eye drop solutions. F 441 483.65 INFECTION CONTROL, PREVENT SS=E SPREAD, LINENS The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 431 F 441 6/24/11

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 85 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 441 Continued From page 85

F 441

This REQUIREMENT is not met as evidenced by: Based on observations, interviews, and record review, the facility failed to ensure that staff follow facility policy for the prevent, transmission and the spread of disease for 4 of 6 sampled residents observed during the medication pass (R28,R2,R30, R31), and failed to implement infection control practices related to storage of linen. Findings include: 1. During the initial tour of the facility on 4/5/11 that began at 9:45 AM, it was observed that fur used bars of soap in the building soap dish in the bathroom of 10. Room 10 is a four bedroom. The soap dish was not labeled with any resident's name. E4 (assistant director of nursing) stated when interviewed at that time that room houses four residents that share the bathroom. E4 further stated that the facility provides the residents with liquid soap only and that the facility does encourage the residents to use liquid soap and not to bring in their own bars of soap. 2. During observation of the medication pass with E17 (nurse) on 4/6/11 at 8:50 AM, E17 was observed to fail to wash/cleanse her hands prior to preparing medications for R28. In addition, E17 was observed to prepare and administer medication to R2, R30 and R31. E17 was of failing to wash her hands inbetween preparing
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 86 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 441 Continued From page 86 medications for each resident. Facility policy "Medication Pass" documents that hand washing must be done with either soap and water or commercially prepared alcohol gel with a minimum of 70% alcohol content....wash hands with soap and water in the following circumstances: before starting the med pass, before and after doing treatments (between each treatment site), before and after administering of eye medications, before and after giving meds through a G-tube, NG-tube, or J-tube, before and after injections, after touching anything obviously contaminated, after physical contact with residents during med pass... E17 stated when interviewed that she was aware that her hands should have been washed or cleansed with sanitizating gel inbetween administering medications to residents During the environmental tour on 4-7-11, at 10:45 am, accompanied by E 14(Maintenance), the following were observed : 1. Boiler Room noted clean linens stored on a cabinet. Interview with E 14 on 4-7-11 at 11:00 am stated that linens are normally not stored in the boiler room. F 463 483.70(f) RESIDENT CALL SYSTEM SS=D ROOMS/TOILET/BATH The nurses' station must be equipped to receive resident calls through a communication system from resident rooms; and toilet and bathing facilities.

F 441

F 463

6/24/11

This REQUIREMENT is not met as evidenced by:


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

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 87 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 463 Continued From page 87 Based on observation, and interview, the facility failed to ensure that all call light devices were working in the facility. Findings Include:

F 463

During the initial tour on 4-5-11 at 9:45 am, accompanied by E 3(Director of Nursing), the following were observed: 1. Room 21-02-bathroom call light button not working. 2. Room 21-07-all call lights in room not working. 3. Room 21-08- all call lights in room not working. 4. Room 21-09- all call lights in room not working. 5. Room 21-10, 21-11, and 21-12, all call lights not working. Interview with E 14 on 4-6-11 at 10:00 am stated that a fuse had blown resulting in the failure of the identified failing call lights. When asked, when was the facility informed of the blown fuse ? E 14 stated that it was discovered on 4-5-11 after the surveyors initial tour. F 492 483.75(b) COMPLY WITH SS=D FEDERAL/STATE/LOCAL LAWS/PROF STD The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

F 492

6/24/11

This REQUIREMENT is not met as evidenced by: Based on interview and record review facility failed to notify local law enforcement and follow state law 300.695 for 2 of 24 (R6,R14) residents
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 88 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 492 Continued From page 88 in a sample of 24. Findings Include: 1) Record review of R14 ' s social service incidental note dated 1-19-11, R14 grabbed the shirt on another resident and then hit the resident and grabbed him by the neck. Both residents were separated by security. Record review of nurse ' s progress dated 1-19-11 at 5:30 PM, R14 attempted to take another resident ' s shirt off, mother and director of nursing notified. Record review of incident report for R4 denotes dated 1-19-11; physician, director of nursing and family notified, police not notified. Record review of nurse ' s progress notes dated 2-13-11 at 1:15 PM; R14 hit another resident in the nose. Family, doctor and director of nursing notified. Record review of the social service incident dated 2-13-11, R14 physically attacked another resident because that particular person grabbed his soft drink. Record review of R14 ' s accident/incident report denotes physician, family, board of health and director of nursing notified; police not notified. Review of incident reports indicates that on 12-11-10 at 6:25 pm, R6 was struck in the face by a resident peer at the facility. Review of the incident report does not give a detailed documented evidence of police notification as evidence by no police star number or police incident report. Interview with E 5(Social Service) on 4-7-11 at 2:00pm stated that the incident report, as well as the nurses notes , would indicate if the police were notified. This was not done. F 514 483.75(l)(1) RES
FORM CMS-2567(02-99) Previous Versions Obsolete

F 492

F 514
Facility ID: IL6001994

6/24/11
If continuation sheet Page 89 of 91

Event ID: HFIG11

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 514 Continued From page 89 SS=D RECORDS-COMPLETE/ACCURATE/ACCESSIB LE The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

F 514

This REQUIREMENT is not met as evidenced by: Based on observation and interview facility failed to have current medication administration record for 1 of 14 residents (R14) in a sample of 24, and failed to follow generally accepted professional standards related to accurate documentation involving 2 of 24 sampled residents (R2,R6) Findings include: During the survey on 4-7-11 thru 4-8-11 observed no April 2011 medical administration record for R14 in the nurse ' s station medication book. Interview with E3 (Director of Nursing) at 9:45 AM on 4-8-11 states the medication administration record has been misplaced and we have not been able to locate it since yesterday. Review of the MAR(Medication Administration Record) dated January of 2011 of R 2 indicates
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 90 of 91

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: 09/23/2011 FORM APPROVED

OMB NO. 0938-0391


(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

04/22/2011

COLUMBUS MANOR RES CARE HOME


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

5107 21 WEST JACKSON BOULEVARD

CHICAGO, IL 60644
PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETION DATE

F 514 Continued From page 90 that resident receives 1 can of 2-Cal nutritional supplement daily. The MAR has blood pressures located where the nurses signatures should be. The MAR also indicates weekly weights. The MAR has pulse rates located where the nurses signatures should be. Review of R 6 record indicates that an order for Ambien 10 milligrams every hours sleep as needed was ordered on 10-20-10. Noted in the record was the consent signed by R 6 but dated 3-3-11. On 4-7-11 at 4:30pm during the daily status meeting, the facility was notified of the concerns.

F 514

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

Event ID: HFIG11

Facility ID: IL6001994

If continuation sheet Page 91 of 91