DEPARTMENT OF HEALTH AND HUMAN SERVICES PRT ORM APPROVED FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB NO. 0938-0391 STATEWENT OF DERGENCES |x) PROVDERSUPPLERICLA | 02) MATIPLE CONSTRUCTION lx) are survey ‘nO PLAN OF CORRECTION pammnernonNUMmER — | onone, Souistes 146063 ne 05/24/2012 TARE OF PROVOER OF SUPPLER STREET ADDRESS, CY. STATE TPCODE 208 SOUTH SECOND STREET eee WALNUT, IL 61376 aap SUMMARY STATEVENT OF OERGENGES T 8 PROVIDERS FAN OF CORRECTION oI Geer | (EAGHDEFICENGY MUST a: PRECEDED BY FULL preroc (ACNCORPECTIE ACTIONSHOULD ee | conknow Tao” | REOUUATORY ORL SC IOENTIEYING REORMATION) ne cages nePeneioes fore aponopranre | | “eae OEPCENCY) F 000] INITIAL COMMENTS F 000 Annual Certification Survey F 157 | 483.10(b)(11) NOTIFY OF CHANGES F 157) (6/20/12 (INJURY/DECLINE/ROOM, ETC) ‘Afacilty must immediately inform the resident; | | consult with the resident's physician; and if known, notify the resident's lagel 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 (Le., a need to discontinue an | existing form of treatment due to adverse | ‘consequences, or to commence a new form of treatment); or @ decision to transfer or discharge the resident from the facility as specified in §483.12(a), The facility must also prompt notify the resident and, if known, the resident’ legal representative or interested family member wien there is a ‘change in room or roommate assignment as specified in §483.15(e\2); of 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. This REQUIREMENT is not met as evidenced \URBORATORY DIRECTORS OR PROVIDERSUPPLIER REPRESENTATIVES SIGNATURE TE aoe ‘Any deficiency statement ending with an astaisk () denotes a deficiency which the insitulon may ba excused fom correcting proving Its determined tat bother safeguards provide sufient protection tothe paints (See instrucions.) Except for nursing homes, the ndings stated above are dsclosable 90 days falloving tho date of survey whether or ota plan of corecton is provided. For nursing homes, the above findings and plans of correcton are disclosable 14 {ays folowing the date these documents are made avaiable tothe faciy, If deficiencies are cited, an approved plan of correction Is requisite to continued program particpation FORM GMS-2867(02.9) Provous Voreione Obclta Event: 02641 Feit i: Le000800 If continuation sheet Page 1 26,PRINTED: 07/07/2014 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES ‘OMB NO. 0938-0351 [STATEMENT OF DEFICIENCIES (XI) PROVIDERISUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION xs) onTe SURVEY /AND PLAN OF CORRECTION IDENTPICATION NUMBER | out owe, COMPLETED 4146063 Bw 05/24/2012 TAvE OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZP CODE 308 SOUTH SECOND STREET eee WALNUT, IL_ 61376 oa ‘SUNARY STATEMENT OF DEFICIENCIES © PROVIDERS PLAN OF CORRECTION 781 PRerik | (GACH DEFICIENCY MUST BE PRECEDED BY FULL REE (GACH CORRECTIVE ACTION SHOULD BE_—_| COMPLENON The REGULATORY OR LSC IDENTIFYING INFORMATION) Tae CROSSREFERENGED TOTHEAPPROPRITE | ONE | DERCENCY) F 487 | Continued From page 1 F187 by: Based on observation, interview and record review the facility failed to follow their own policies and failed to notify the physician regarding unplanned significant weight loss for two of five residents reviewed for weight loss (R10, R14) in the sample of 15. The facility failed to notify the physician regarding the development of a pressure ulcer for one of one resident (R10) Teviewed for pressure ulcers in the sample of 15. Findings include: | 1. Nurses notes dated 03/12/12 and Admission Nursing Assessment state that R10 was admitted ‘on 03/12/12, weighing 97 pounds, 5 foot 3 inches tall, On 05/21/12 at 1:30 p.m., R10 was transferred from her reclining chair into bed. R10 is very thin and bony. The facilty’s Weight Management Protocol dated 10/2005 states that newly admitted residents will be weighed within the first 24 hours of admission and weekiy forthe first four months of residency. This protocol also states that any resident with a significant weight loss (over 5% in one month) will be referred to the consulting dietitian and the resident's Power of Attorney and physician will be notified ‘The Monthly Record of VIS (vital signs) and weights documents that staff did not weigh R10 weekly and next weighed R10 on 04/10/12 when R10 weighed 84 pounds. This is a 13% weight loss in one month, 10's clinical record does not include any documentation that R10's physician was notified of her 13% weight loss, On 05/23/12 at 9:30 a.m., FORM GMS 25071029) Previous Varios Obsaeta Event D:BR2611 acy: 6008600, IWeontinvaion shest Page 2 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES. CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0394 | noted to have the unplanned significant weight | | loss). 2, Nurses notes dated 03/12/12 and Admission Nursing Assessment state that R10 was admitted ‘0n 03/12/12, with one Stage I! pressure ulcer on. her right inner buttocks. On 05/21/12 at 1:30 p.m., R10 was transferred from her reciining chair into bed. Two Stage It pressure ulcers are present on her sacral area, | ‘open and draining serosanguinous onto her incontinent brief. ‘The weekly pressure ulcer documentation form documents that nurses identified a second Stage II pressure ulcer on R10 on 05/12/12. R10's clinical record does not include documentation that the physician was notified of the development of a second pressure uleer. (On 05/29/12 at 9:30 a.m., €2 verified that the facility did not notify R10's physician of the development of R10's second stage Il pressure Ulcer. 3. R14’s POS (physician order sheet) dated 05/01/12 through 05/31/12 list R14a's diagnoses of Parkinson's, dementia, insomnia, depression and amety R14 was weighed on the day of admission STATEMENT OF DEFICIENCIES Ki) PROVIDERSUPPLIERICUIA | (Xz) MULTIPLE CONSTRUCTION (xs oare sunvey AND PLAN OF CORRECTION IDENTIFICATIONNUMBER | to COMPLETED 148063, B.wing 05/24/2012 NiE GF PROVIGER OR SUPPLIER STREET ADDRESS, GY, STATE AP CODE 308 SOUTH SECOND STREET ecemeeemeeaes WALNUT, IL 61376 ea ‘SUNAWARY STATEVENT OF DENOENGES © PROVIDERS PLAN OF CORRECTION. a, Prt | (GAGHDEFICENCY MUST BE PRECEDED bY FULL PREFEK (ACHCORRECTNE ACTION SHOULD BE coupon AG. | REGULATORY OR LSC IDENTIFYING INFORMATION) the CAOSS-REFERENCED TOTHE APPROPRIATE "ONE DEFICENCT) F 187) Continued From page 2 F157] 2 (Director of Nurses) verified that the facility did ‘ot notify R10's physician of R10's unplanned significant weight loss, £2 provided R10's physician's office records that document R10 had an office visit and was weighed in the physician's office on 04/18/12 (eight days after R10 was FORM ONS-2567(02 00) Previous Verdons Obsaats Even DBRS city 10106000600 i ontinuaton sheet Pago of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES, CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0394 STATENENT OF DEFICIENCIES —_[(X1) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION IBENTIEICATION NUMBER 148063 (02) MULTIPLE CONSTRUCTION A.BULDING, 8. WING. xs) bare suRVEY COMPLETED 05/24/2012, ‘NaNE OF PROVIDER OR SUPPLER WALNUT MANOR 308 SOUTH SECOND WALNUT, IL 61376 ‘STREET ADORESS, CTV, STATE, ZP CODE ‘STREET ‘SUMMARY STATEVENT OF DEFIGENGIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) 4) PREFIX D. PROVIDERS PLAN OF CORRECTION ea PREF (EACH CORRECTIVE ACTION SHOULD Be | cowP.snoN TAG (ROSS-REFERENCED TO THE APPROPRIATE. ote DEFICENCY) F 157| Continued From page 3 11/02/11, and was not weighed again until 12/04/11, thirty-two days later. There is no documentation in R14's medical record of POA or physician notification after the monthly record of vital signs and weights indicates R14 lost eighteen pounds from 12/04/11 to 01/05/12. 14's monthly record of vital signs and weights for the years 2011 and 2012 documents on 12/04/14 that R14 weighed 176 pounds and on (01/05/12 that R14 weighed 158 pounds, a loss of eighteen pounds (a 10.2% loss over a thirty-two day period.) Documentation of POA or physician notification of this weight loss was not present in Rt4's medical record, 14's most recent MDS (Minimum Data Set) dated 02/09/12 indicates that R14 has a loss of 5% or more in the last month or loss of 10% or more in the last six months, and is not on a physician-prescribed regimen. Physician progress notes indicate that after the documented weight loss of 18 pounds on 01/05/12, R14 was not seen by the physician until 01/27/12. Atthis time, a physician order was written placing R14 on a nutritional supplement. ‘On 05/22/12 at 1:27 p.m., E8, (Corporate Nurse), confirms that documentation of physician notification is not on the monthly record of vital signs and weights, "where i's supposed to be." F 258 | 483.15(h\(7) MAINTENANCE OF =D | COMFORTABLE SOUND LEVELS The facility must provide for the maintenance of comfortable sound levels. F157 F 258 6/20/12 FORW CNS 256710299) Provous Vere Obsolete ‘Event BROS Fac 5000600 i eontinualion sheet Page 4 0126,DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENTOF OEFICIENGIES —_|[Xt) PROVIDERISUPPLIERICLIA | 2) MULTIPLE CONSTRUCTION 2s) bare survey ‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER: emirate [COMPLETED 146083 8. WING. 05/24/2012, ANE OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZP CODE 308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 This REQUIREMENT is not met as evidenced by: Based on observation and interview the facilty failed to provide comfortable sound levels for one of 16 residents (R2) observed for comfortable sound levels in the sample of 16 and one resident (R21) off the sample. Findings include: During the individual interview of R2 on 5/21/12 at 10:51 am, it was stated by the resident that the noise from closing doors in the hallway was distracting and made it difficult for her to concentrate because it happens multiple times on a dally basis. R2 stopped several times during the conversation to mention that this loud slamming was annoying to her at the time it was occurring during this individual interview. R2 stated that she did discuss this matter with her son present at the latest carepian meeting. "The door siams all the time. The only bothersome noise is to the nurse's door (employee lounge). ‘That is the only thing | have complained about’ On 5/24/12 at 3:14 pm, another resident, R21, whose room is adjacent to the employee lounge verified that "they stam that door (pointed towards the employee lounge) next door alot’. Interview with E5 (Careplan Coordinator) on 5/22/12 at 9:05 am confirmed that she was made | aware of the situation as distraughtful to the resident. E5, said she put a sign on the inside of the employee lounge door - "Please do not slam. the doorit!! Bothersome to residents Thanks!!!" (oa) ‘SUNWARY STATEMENT OF DEFCIENOIES 0 ‘PROVIDERS PLAN OF GORREGTION 7a) Fete | (EACH OSFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | couPLzon. TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG ‘CROSS-REFERENGED TO THE APPROPRIATE ‘one DEFICIENCY) F 258] Continued From page 4 F 268 FORM CHS 2507(02 68) Previous Versions Obsaate ‘Even I: BROS " acy 10: 45000600 if continuation sheet Page 6 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED. OMB NO. 0938-0394 STATEMENT OF DEFICIENCIES | (XI) PROVIDERISUPPLIERIGUA AND PLAN OF CORRECTION IDENTIFICATION NUMBER 146063, (0) MULTIPLE CONSTRUCTION A.BULDING, 8. WING fxs) oare suRvEY ‘COMPLETED 05/24/2012 WANE OF PROVIDER OR SUPPLIER WALNUT MANOR ‘STREET ADDRESS, OY, STATE, 2 CODE 308 SOUTH SECOND STREET WALNUT, IL 61376 “SUMMARY STATEMENT OF DEFICIENCIES (GACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR USC IDENTIFYING INFORMATION) ea) PREF TAG. ry PREFIX TAS ‘PROVIDERS PLAN OF CORRECTION 2, (GACH CORRECTIVE ACTION SHOULD BE | cowplerion (OROSS-REFERENCED TO THE APPROPRIATE oat DEFICIENCY) F 258 | Continued From page 5 Observation of the 200 hall employee lounge and clean linen door on /21/12 from 2:55 pm to 3:10 PM noted that the doors slammed loudly a total of, eight times as the staff entered or exited as follows: 2:55 pm to 3:05 pm-three loud slams of the ‘employee lounge door 3:07 pm-two loud slams of the clean linen door 3:08 pm-3:10 pm-three loud slam of the ‘employee lounge door Itwas verified by E10, Certified Nurses Aide, that from 3:10 pm to 3:20 pm, E10, opened and closed the clean linen room door five times. 483,25 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING Each resident must receive and the faclity 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 This REQUIREMENT Js not met as evidenced by: Based on record review and interview, the facility failed to assess and evaluate the effectiveness of a scheduled pain medication for one of six residents (R2) reviewed for pain management in the sample of 15, Findings include: R2's care plan dated 05/10/12 addresses the focus, "Alteration in comfort related to: F 258 F309 er2012 FORA CUS 256710299) Previous Versio Obese Event OrBRI5Tt acl: 5000600, i continuation sheet Page 6 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0391 Musculoskeletal impairment, Neurological impairment, diagnosis of DJD (degenerative dise disease), wedge compression of L1 and L3, and extreme low back pain’. Interventions for this focus instructs facility nursing staff to, “complete pain assessment," and to, "Observe resident for effectiveness of pain relief". No documentation of a pain assessment was completed on R2's MAR (medication administration record) from 05/01/12 through 05/21/12 or documented in R2's medical record. R2's Pain Questionnaire assessment dated 05/10/12 identifies R2 as having more than one pain, R2 stated on 05/21/12 at 11:05 a.m., "| used to be ‘on a pain patch, but it got stopped because they ‘sald I was too drowsy. | do have aches and pains ‘every once in awhile- they bring me a hot pack at night when I ask for one”. R2's MAR dated 05/01/12 through 05/31/12, documents that R2 is receiving acetaminophen (Tylenol) 325 mg (milligrams) twice daily for "pai not elsewhere classified”. No pain assessment for effectiveness of this scheduled twice daily dose is documented on R2's MAR or in R2's medical record from 06/01/12 through 06/21/12 E15, LPN (Licensed Practical Nurse) stated on 08/22/12 at 9:35 a.m, "it's (pain assessment) not being done and it should be," and confirmed that pain assessment is, "supposed to be written on the MAR", On 05/22/12, the Facilty Policy: Management of Pain, under section 10. Documentation, states, conditions/diagnosis associated with potential for | STATENeNTOFDERCENCES —— |cKt) PROVDERSUPPLERCLA | a) RATRLE CONSTRUETON os onte survey Mopuinor conrecrion Senincaroncer’ | RAMAN Ouro 140003, swing os2a012 THE OF PROVOER RSA SIREETAOORESS, OTY SNE EP CODE 208 SOUTH SECOND STREET ee WALNUT, IL 61376 Ta |, SORRY STEHT OF DERNOES . PROWDERS PLAN OF CORRECTION ry SOR.) excibencency mist ae rrectoeb ay ru. vatrx | exenonrcerveacronsroupee | coufZnon MheN | AESUUATORY ONS ENTE NG FORTIN, Teo’ | cleSererenences forme apoornre | “Tone SEFCIENCY) F 309 | Continued From page 6 F309 FORW CNS 2587102 99) Prevous Verde Obeaiate Event IBRSSH 7 Foci 018000600 Ifeontinuatn sheet Page 7 of 26,PRINTED: 07/07/2014 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED. CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0364 STATEMENT OF DEFICIENCIES |[Kt) PROVIDERISUPPLIERICLIA | 12) MULTIPLE CONSTRUCTION xs) ore suRVEY J AND PLAN OF CORRECTION UDENTIFICATION NUMER: amr ‘COMPLETED 146083 awn 05/24/2012 ANE OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CIV, STATE, 2P OODE 308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 (oa) 0 “SUNIMARY STATEMENT OF DEFICENGIES a PROVIDERS PLAN OF CORRECTION 2 Beer | (GACHDEFICIENCY MUST BE PRECEDED BY FULL PREFIX (GACH CORRECTIVE ACTION SHOULD BE__| coMPueoN Tas. REGULATORY OR LSC IDENTIFYING INFORMATION) TAS (OROSS-REFERENGED TO THE APPROPRIATE are DEFICIENCY) F 309| Continued From page 7 F309, jocument interventions and responses in the ‘medical record as appropriate and on the pain flow sheet’. No interventions or responses are documented on R2's MAR or in R2's medical record, E2 confirmed on 06/23/12 at 9:16 am., that no pain assessment for effectiveness of scheduled ‘Tylenol dose has been documented on R2’s MAR dated 05/01/12 through 05/21/12 and stated, “they should have been doing ths”. F 314] 483.25(c) TREATMENT/SVCS TO F 34) 620112 PREVENT/HEAL PRESSURE SORES Based on the comprehensive assessment of a | resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the | individuat's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing, This REQUIREMENT is not met as evidenced by: | Based on observation, interview, and record review, the faciity failed to protect the pressure ulcer area from friction and contamination and failed to implement nutritional interventions to promote healing for one of one residents (R10) reviewed for pressure ulcers in the sample of 15. R10's pressure area present on admission | deteriorated and R10 developed a second Stage | Il pressure ulcer. Findings include: | FORM CMS 2567(02 99) Previous Verions Cbecet Event :BRSSII Fai 1D Le000650, if continuation sheet Page 8 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0394 Nurses notes dated 03/12/12 and Admission Nursing Assessment state that R10 was admitted | on 03/12/12 with one Stage Il pressure ulcer on her right inner buttocks. The Ulver Care plan and Treatment Plan dated 03/12/12 states that R10 was admitted with one | stage Il pressure ulcer on her sacrum, which measured 1 centimeter by 1 centimeter. ‘This form includes weekly measurements and pressure ulcer documentation. According to this, | form, on 05/10/12 R10's pressure ulcer had improved to a superticial area 1 centimeter by 0.5, centimeters. On 05/21/12 at 1:30 p.m., £18 and E19 (both CNAs-Certified Nurse Aides) transferred R10 from her reclining chair onto the commode then. into bed. R10 is very thin, bony, and has two stage Il pressure ulcers present on her sacral area. There was no dressing covering either pressure ulcer and the ulcers had drained serosanguineous drainage onto R10's incontinent brief. E18 verified that no dressing was present on R10's sacral area and stated that there was no dressing on R10's pressure ulcers at 7:30 a.m., when she (E18) got R10 up out of bed. The weekly documentation on this form documents that nurses identified a second stage Il pressure ulcer on R10 on 05/12/12, measuring 0.5 x 0.5 centimeters. (On 05/21/12 at 1:40 p.m., E21 (Registered Nurse) performed a treatment to R10's two | pressure ulcers. E21 verified that no dressing was present on R10's sacrum. The incontinent pad under R10 had a small amount of serosanguineous drainage present where R10's STATENENT OF DEFICIENCIES (Ki) PROVDERSUPPLIERICLIA | (2) MULTIPLE CONSTRUCTION Jos) Dare SURVEY [AND PLAN OF CORRECTION DENTIICATIONNUMDER” = | atone COMPLETED 148063 ewig 05/24/2012 TUE OF PROVIOER OR SUPPLIER ‘STREET ADORESS, GY, STATE, AP CODE 308 SOUTH SECOND STREET WALNUT MANOR , a WALNUT, IL 61376 or “SUMMARY STATENENT OF DEFCIENGIES D ‘PROVIDERS PLAN OF CORRECTION = Peer | (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREF (EACHCORRECTVE ACTION SHOULD BE_—_| couPLETON Tae | REGULATORY ORLSCIDENTIFYING INFORMATION) he CROSS REFERENCED TO THE APPROPRIATE | DATE DEFICIENCY) F314 | Continued From page 8 F314 FORM ClS-2567102-9) Previous Versions Obsolete Event: BR35it Fey © 6008600 | Tf contauation sheet Page @ of 28DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0394 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPFLIERICLIA [AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 146063 (02) MULTIPLE CONSTRUCTION A BULDING a. WING. xs) Dave suavey (COMPLETED 05/24/2012 TNE OF PROVIDER OR SUPPLIER WALNUT MANOR 1308 SOUTH SECOND, WALNUT, tL 61376 ‘STREET ADDRESS, CITY, STATE, ZP CODE STREET 40 PREFIX TAG. “SUWMARY STATEMENT OF DEFICENCIES (GACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) o PROVIDERS PLAN OF CORRECTION 2, PREFIX (EACH CORRECTIVE ACTION SHOULDBE | cowPueToN TAS. (CROSS-REFERENGED To THE APPROPRIATE ‘are DEFICIENCY) F314 Continued From page 9 pressure ulcers had been in contact with the pad. ‘The top pressure ulcer was round 4 x 1 | centimeter in size, open and yellow with redness surrounding the ulcer. The lower pressure ulcer was 1.25 x2 centimeters in size also open, yellow’ | with surrounding red peri-wound area. According to the Nutritionel Assessment signed by E17 (Registered Distitian)on 04/06/12, R10 ‘weighed 97 pounds with a low Basal Metabolic Index of 19 and a Stage Il pressure ulcer. E17 documents that R10 Is on a general diet with 60 ce supplement twice daily. E17's recommends to monitor R10's weight closely and promote gradual weight gain, The monthly weight log documents that R10 had a significant weight loss when next weighed on 04/10/12 at 84 pounds. R10's clinical record does not include any assessment or evaluation of R10's significant Weight loss and increased nutritional needs related to the development of a second pressure ulcer and no recommendations to promote healing. ‘The facltys Ulcer Policy and Procedure dated 08/2010 states that when a resident is found to have an ulcer, the physician will be notified and ‘orders for Vitamin C daily and Zine Sulfate 220 mmiligrams may be requested as well as a | treatment order. According to the physician's order form, R10 does not receive Vitamin C or Zinc Sulfate, and nurses notes do not include any documentation stating that R10's physician had been notified regarding the development of R10's second pressure ulcer or whether R10's physician ‘would want Vitamin C andlor Zinc added to R10's medication regime to aid in healing of the pressure areas. F314 FORM CHS-2557(0208) Previous Versions Obssite Event IBS oy 116008600, I eontnuation sheet Page 10 of 28DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0394 STATEMENT OF DEFICIENCIES |X!) PROVIDERISUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION [AND PLAN OF CORRECTION. IDENTIFICATION NUMBER: | aaiiaee) 148063 B.WING. (xs) are suRVEY ‘COMPLETED 05/24/2012 308 SOUTH SECOND WALNUT MANOR WALNUT, IL. 61376 THANE OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZP CODE STREET mam UnIARY STATEMENT OF DERCENGES | _fROWaERS RANOF ORECTON a Bieri | eactenencr wists rreccoeD oy FUL paeex | (EACH ORBECTWE ACTION SHOULD Be | covhron The | sESULATORY ORL SE DenTING REORATTON Teo | chetenerenences fo Tse aronomniare || “one DEFICIENCY). F314) Continued From page 10 Fat4 10's clinical record does not include documentation that the physician was notified of | the development of a second pressure ulcer. (On 05/23/12 at 9:30 a.m., E2 verified that the facllty did not notify R10's physician of the development of R10's second stage Il pressure ulcer. Six days after the development of R10's second pressure ulcer, the nurses obtained a physician's order dated 05/18/12 instructing nurses to administer med pass supplement 120 cc three | times daily per faclity’s wound protocol ‘The care plan dated 03/29/12 identifies that R10 has a pressure ulcer, but fails to address that R10 has developed a second pressure ulcer, This ‘care plan instructs staff to monitor R10's nutritional status but does not provide specific approaches for staff to utllize to improve R10's rutrtion and promote healing of her pressure | ulcers. This care plan does not provide instruction | to staff regarding treatment of R10's pressure areas. (On 05/22/12 at 1:35 p.m., E8 reviewed R10's care plan and verified that R10's pressure ulcer status was not current on her care plan and no plan was developed to promote R10's weight gain and interventions were incomplete to promote pressure ulcer healing. F 323] 483.26(h) FREE OF ACCIDENT F323 HAZARDS/SUPERVISIONIDEVICES. The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives le/20/12 FORM CUS 256710290) Previous Vaslors Obsclete Event -BRESTY ae 1018000800 {Weontination sheet Page 11 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 07/07/2014 FORM APPROVED. CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0304 ‘STATEMENT OF DEFICIENCIES |(X1) PROVIDERISUPPLIERICLIA | (x2) MULTIPLE CONSTRUCTION (xs) are SURVEY [AND PLAN OF CORRECTION. IDENTIFICATION NUMBER: amram COMPLETED 146063, 8.WING. = 05/24/2012 THANE OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, 2 CODE WALNUT MANOR 308 SOUTH SECOND STREET WALNUT, IL 61376 4) “SUMIARY STATEMENT OF DEFIOENOES D PROVIDERS PLAN OF CORRECTION 2 Pree | (GACH DEFICIENCY MUST 8E PRECEDED BY FULL, PREFIX (EACH CORRECTIVE ACTION SHOULD BE _—_—coMRLETON TAs. REGULATORY OR LSC IDENTIFYING INFORMATION) TAS (CROSS-REFERENCED TO THE APPROPRIATE are DEFICIENCY) F 323] Continued From page 11 F323 | adequate supervision and assistance devices to prevent accidents. ‘This REQUIREMENT Js not met as evidenced by: Based on interview and record review, the facility, failed to apply and monitor moist hot packs in a manner to prevent the development of a burn for ‘one of one resident (R1) who receive hot packs in the sample of 15. This failure resulted in R1 sustaining a two centimeter ful thickness burn which required two months to heal Findings include: Nurses notes dated 02/27/12 (no time. documented) state that a CNA was showering Rt and noted a red broken blister area on R1’s right shoulder. This circular area measured 2 centimeters. Nurses notes state that R1 said "Therapy got that too hot, after they put a hot pack on me Sat. (Saturday)" The facility's Occurrence Report dated 02/27/12 and investigation dated 02/28/12 completed by 2 stated that "Upon conclusion of all interviews, including the resident." (R1) "received a 2 om, bum on her right shoulder from a hot pack placed om her Rt. (right) shoulder by therapy.” This investigation includes documentation of an interview with E16 (Occupational Therapist, who stated that she had treated R1 on 02/24/12 after lunch and placed hot packs from the hydrocolator, (on R's right shoulder. E16's statement R{1 stated that "this is getting hot." E16's documents that after 5 minutes into the treatment | FORM OWS-2667102-90)Provious Valens Obsolete Event D:BRG6T acy L8000800, ieontinuation chest Page 12 of 28DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0394 statement documents that she removed the towel and the hot pack and placed a second towel down and replaced the pack. E16's statement says that when E16 remioved the final hot pack, she (E16) noticed an area of redness and moisture like water on R1's skin. E16's statement continues stating, "maybe I didnt drain all the water off, 'm not sure why it gt so hot.” The facility's inservice information dated 02/29/12, states when applying moist heat packs to apply 4-6 layers of towels or 2 layers of commercial towels, Physician's order dated 02/27/12 instructed nurses to apply Silvadene cream to R1's burn twice daily. The facility's Wound Care Plan Treatment Plan dated 02/27/12 documents Rt's wound type as a bum on right shoulder, ‘measuring 2 by 2 cm. The Patient Wound Care Order Sheet dated 03/01/2012 by the consulting wound nurse states that R1's burn wound is a full thickness wound and has increased to 2 by 2.6 ‘om. This documentation states that R1's wound bed is light brown/grey thin eschar, with thin fragile pink peri-wound tissue. ‘The Patient Wound Care Order Sheet dated (04/02/12 by the consulting wound nurse states that R's bur is 100% yellow brown slough with thin pink fragile peri-wound tissue with a light purple discoloration 2 em. perimeter. This form documents that the treatment for R1 was changed to an enzymatic debridement agent ‘Santyl with Hydrogel gauze to maintain a moist wound environment with a bordered foam dressing to protect the frail, fragile tissue. ‘The April 2012 Treatment Administration Record STATEMENT OF DEFICIENCIES [(X1) PROVIDERISUPPLIERICLA | (X2) MULTIPLE CONSTRUCTION Jos) ate SURVEY [AND PLAN OF CORRECTION IDENTIFICATION NUMBER aati COMPLETED 146063 8. WING 05/24/2012 ‘RANE OF PROVIDER OR SUPPLIER, ‘STREET ADDRESS, CITY, STATE. ZIP GODE 308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 ay “SUNIMARY STATEMENT OF DEFIOENOIES © PROVIDERS PLAN OF CORRECTION 2) Peer | (GACH DEFICIENCY MUST 9€ PRECEDED BY FULL PREFIX (GACH CORRECTIVEACTION SHOULD BE | COMPLETION Tas. REGULATORY OR LSC IDENTIFYING INFORMATION) "ae ‘OROSS-REFERENCED TO THE APPROPRIATE ATE DEFICIENCY) F 323] Continued From page 12 F323 FORM CUS-2587(0299) Previous Versions Obasite Event I: BROSit Fit 10 .6009600| ‘Weontinuaton shoot Page 13 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES. CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO, 0938-0391 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 rutrtional problem. This REQUIREMENT Js not met as evidenced by. Based on observation, interview, and record review, the facility failed to follow their weight Management Protocol and failed to comprehensively assess, determine the cause of ‘an unplanned significant weight loss, develop and implement interventions to promote weight gain or prevent further weight loss for one of five residents (R10) reviewed for weightloss in the sample of 15. Findings include: Nurses notes dated 03/12/12 and Admission STATEMENT OF DEFIGIENGIES (Kt) PROVIDERISUPPLEERIGLIA] 0d) MULTIPLE CONSTRUCTION lo oare suRvEY JANG PLAN OF CORRECTION ibewrmncarionnummer — | run one COMPLETED 148063 swing 05/24/2012 TAIE OF PROVIDER OR SUPPLER ‘STREET ADDRESS, GI, STATE, 2P CODE 2308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 ‘enim “iA STATEVENT OF DERIOENOES D PROVIDERS PLAN OF CORRECTION 7 GOR | exch ercenoy must oe preceDeD ey FULL PREF (cachiconnecTiveAcTIoNsHoULD Be | coMt2now Tha | AEGULATORY OR LSC IDENTIFYONG NFORHATION) THe CAOSEREFERENGED TOTNE APPROPRINTE | ONE DEFICENCY) | F 323| Continued From page 13 F323 documents that R1's burn was healed and treatment discontinued on 04/23/12, ‘On 05/28/12 at 9:20 a.m., E2 confirmed that she had completed an investigation of R's burn and determined that the cause of R's burn was from the application of the hot packs. F 325 483.25()) MAINTAIN NUTRITION STATUS F 925 6120/12 8820 | UNLESS UNAVOIDABLE FORM CNS 256710299) Previous Versions Obsokie ‘Event I/BRISN| Fay: 6000600 Teentinuation sheet Page 14 of 28DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 07/07/2014 FORM APPROVED. CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0364 [STATENENT OF DEFICIENCIES (Kt) PROVIDERSUPPLIERICLIA | (2) MULTIPLE CONSTRUCTION Joc DATE SURVEY /AND PLAN OF CORRECTION IDENTIFICATION NUMBER, amram (COMPLETED 146063 8. WING. osrearoni2 'NANE OF PROVIDER OF SUPPLER, ‘STREET ADDRESS, CITY, STATE, 2 CODE 308 SOUTH SECOND STREET Nursing Assessment state that R10 was admitted on 03/12/12, weighing 97 pounds, 5 foot 3 inches tall, and has one stage Il pressure uloer on her right inner buttocks. (On 05/21/12 at 1:30 p.m., R10 was transferred from her reclining chair into bed. R10 is very thin, bony, and has two Stage Il pressure ulcers present on her sacral area. Admission orders dated 03/12/12 instructs staff to provide a general diet with a house supplement twice daily, ‘The Nutritional Assessment signed by E4 (Food Service Supervisor) on 04/03/12 and E17 | (Registered Dietitian) on 04/06/12 states that R10 ‘weighs 97 pounds and her desired weight range is 107-182 pounds. E17 documents that R10 has a low Basal Metabolic Index (BMI) (less than 19), receives a general diet with 60 oc (cubic centimeters) house supplement twice daily, and has only fair meal intake. E17 instructs staff to monitor weights closely to promote gradual weight gain. The facility's Weight Management Protocol dated 10/2008 states that newly admitted residents wil be weighed within the first 24 hours of admission and weekly for the first four months of residency. This protocol also states that any resident with a significant weight loss (over 5% in one month) will be referred to the consulting dietitian and the resident's Power of Attorney and physician will be notified. | The Monthly Record of ViS (vital signs) and | weights documents that staff did not weigh R10 Lweekiy and next weighed R10 on 04/10/12 when WALNUT MANOR WALNUT, IL 61376 He) | 'SUNWARY STATEMENT OF DEFICIENCIES © PROVIDERS PLAN OF CORREGTION ry Prevx | (GACH DEFICIENCY HUST BE PRECEDED ay FULL PREFIX (GACH CORRECTIVE ACTION SHOULD BE | couPierion TAG REGULATORY ORLSC IDENTIFYING INFORMATION) Tas. (OROSS-REFERENCED TO THE APPROPRIATE. are DEFICIENCY) F 325| Continued From page 14 F 325 FORM CUS-2567102-99) Provo Versions Obscla vat IRS ey Le008600| ‘continuation sheet Page 15 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. PRINTED: 07/07/2014 FORM APPROVED. OMB NO. 0938-0394 R10 weighed 84 pounds. This is a 13% weight loss in one month, 10's clinical record does not include any documentation that R10's physician was notified | of her 13% weight loss. On 05/23/12 at 9:30 a.m., 2 verified that the facilty did not notify R10's physician of R10's unplanned significant weight loss and provided R10's physician's office records that document R10 had an office visit and was ‘weighed in the physician's office on 04/18/12 (eight days after R10 was noted to have the Unplanned significant weight loss). The weekly pressure ulcer documentation form documents that nurses identified a second Stage I pressure ulcer on R10 on 05/12/12. R10's clinical record does not include any assessment or evaluation of R10's significant ‘weight loss and increased nutritional needs related to the development of a second pressure tlcer. R10's clinical record including her care plan does not include the development of any plan to promote weight gain or prevent further weight loss. There is no evaluation of R10's unplanned significant weight loss and no recommendations to promote healing and weight gain by the E17-consulting Registered Dietitian. On 05/22/12 at 1:05 p.m., E4 verified that E17 has not reassessed of evaluated R10 regarding her (R10's) significant weight loss. E4 stated that E17 was in the facility on 05/17/12, but she (E4) has 1no documentation or recommendations from E17 regarding R10. ‘The Dietary Progress notes dated 04/03/12, 04/13/12, and 04/16/12 were reviewed with E4 on 05/23/12 at 1:05 p.m. E4 confirmed that these STATEMENT OF GERGIENGES (KI) PROMIDERISUPPLIERCLA | (3) MULTIPLE CONSTRUCTION xa oare survey AND PLAN OF CORRECTION IDENTIPEATINNNRER — | oon one, CONUS 146063 awn e 05/24/2012 TANE OF PROWGER OR SUPPLER ‘STREET ADDRESS GVY. STATE TP CODE 208 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 Dan |, SUMMARY STATEMENT OF DEROENGES 3 PROVDERS PLAN OF CORRECTION = Miah | eacttoenctency inst Bs PRECEDED By FULL rex (ACHCOMMESTIE ACTIONSHOUDIE | coMnow To” | RECUUATORY ORISE IDENTIFYING REORMATION) Tee | choseherenencea to mearmnormare | ° ORE ORFICENGT) F 825] Continued From page 15 F925 | FORM OMS-2567102.90) Previous Verdana Obecat Tevet BROS city L8000880| If continuaton sheet Page 16 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED. OMB NO. 0938-0361 STATEMENT OF DEFIGIENGIES |X!) PROVIDERISUPPLIERIGLIA [AND PLAN OF CORRECTION IDENTIFICATION NUMBER” 146063 (02) MULTIPLE CONSTRUCTION A BULONG 2.WiNG fxs) oare survey COMPLETED 05/24/2012 ANE OF PROVIDER OR SUPPLIER WALNUT MANOR 308 SOUTH SECOND WALNUT, IL 61376 ‘STREET ADDRESS, CIV, STATE, ZIP CODE STREET a “SUMBIARY STATEMENT OF DEFICIENCIES Prerx | (GACH DEFICIENCY MUST BE PRECEDED BY FUL Tas. REGULATORY OR LSC IDENTIFYING INFORMATION) © ‘PROVIDERS PLAN OF CORRECTION oe, PREFIX (GACH CORRECTIVE ACTION SHOULDBE___| coMALerIOn TAG (GROSS.REFERENGED TO THE APPROPRIATE Bare DEFICIENCY) F 325] Continued From page 16 notes were written by her (E4) and address R10's assistive devises, food and dining preferences, but do not address R10's unplanned significant ‘weight loss or development of the second stage It pressure ulcer. (On 05/21/12 R10 ate 50% of her noon meal. The Nurse Aide flow sheet documents dated 05/13/12- 05/22/12 documents that R10 ate very poorly with an average intake of 15% during that time. R10's care plan dated 03/29/12 does not | address R10's unplanned significant weight loss, and does not instruct facility staf in approaches to promote R10's weight gain | On 05/22/1 at 1:36 p.m., R10's unplanned significant weight loss and her (R10's) development of a second pressure ulcer were discussed with E8. E8 reviewed R10's care plan and verified that R10's weight loss was not addressed and no plan was developed to promote R10's weight gain. No interventions to promote R10's nutrition were implemented for thirty-eight days after R10's significant weight loss was identified when a physician's order dated 05/18/12 instructs nurses to administer 120 ce of med pass supplement three times daily per wound protocol F 329| 483.25(I) DRUG REGIMEN IS FREE FROM s8=D| 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 F325 F329 6120/12 FORM CNS 2587(0200)Prevous Versions Obsste Event IDBROS Feely OL 5000600 I continuation sheet Page 17 of 28DEPARTMENT OF HEALTH AND HUMAN SERVICES PRINTED: 07/07/2014 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES ‘OMB NO. 0938-0391 [STATEMENT OF DEFIGINCEES | pxt) PROVIKERSUPPLIERICUIA | pk) MULTIPLE CONSTRUGTION oo) oare suRVEY [AND PLAN OF CORRECTION IDENTRICATIONNUMBER. | Roun COMPLETED 146063 8.WING 05/24/2012 NAME OF PROVIOER OR SUPPLER ‘SHREETADDRESS, GTY STATE P CODE 308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 a0 SUMMARY STATENENT OF DEFIIENGES > PROVIDERS PLAN OF CORRECTION 7 Patra | (GACH DEPICENGY Must BE PREGeDeD ay FULL PREF (EACHCORRECTIVE ACTION SHOULD BE | combitnon TAS | RECULATORY On Se DENTIFYING INFORMATION) Ae CHOSS-REFERENGED TOTHE APPROPRIATE | ONE DEFICENCY) F 329| Continued From page 17 F329 without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose ‘should be reduced or discontinued; or any 1 ‘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 siven 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 | rugs. This REQUIREMENT is not met as evidenced by. Based on observation, interview and record review the facilty failed to provide ciinical justification for the use of three antipsychotics and justify behaviors to warrant the use of antipsychotics for one of six residents (R15) reviewed for antipsychotics in the sample of 15. Findings include: POS dated 6/2/11 documents R15 was taking Abilify 5 mg daily, Zoloft 150 mg daily, Seroquel 200 mg at bedtime, Trazadone 25 mg at bedtime, Risperdal 1.5 mg at bedtime, and Xanax 0.25 mg | three times a day. R15's POS dated 6/2/11 | R15 was admitted to the facility on 6/2/11. R16's | | | FORM OMS 250710299) Previous Versions Obsolete ‘Even BRST! Fact 6000600 Tf continuation shest Page 18 of 25DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF OEFIGIENCIES —_[(X1) PROVIDER'SUPPLIERICLIA ‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER” 146063 (02) MULTIPLE CONSTRUCTION B.WING A BULOING xs) bare SURVEY (COMPLETED 05/24/2012 RANE OF PROVIDER OR SUPPLIER WALNUT MANOR 308 SOUTH SECOND WALNUT, IL, 61376 ‘STREET ADORESS, CITY, STATE, IP CODE STREET oo “SUNBIARY STATEMENT OF DEFIGENOES, Patek | (GACH DEFICIENCY MUST BS PRECEDED BY FULL TAS. REGULATORY OR LSC IDENTIFYING INFORMATION) io ‘PROVIDERS PLAN OF CORRECTION me PREFIX (GACH CORRECTIVE ACTION SHOULD B= | couPuzrion TAG (CROSS-REFERENGED TO THE APPROPRIATE. are DEFICIENCY} F 329] Continued From page 18 documents diagnoses of Dementia, Bipolar, anxiety, depression, Bipolar affective disorder, manic with psychotic behaviors and Bordertine Personality Disorder. R15's POS dated 511/12 through 5/31/12 documents R15 is currently receiving Zoloft 150 mg daily, Xanax 0.25 mg twice daily, Risperdal 1.5 mg at bedtime, bedtime and Aricept 5 mg daly. R15's psychiatric progress note dated 4/27/11 documents under Behaviors Manifested R15's behaviors are alert, friendly and restiess. On the psychiatric progress note under the section titled Peychialric progress notes and doctors orders it is documented for R15 "seen for follow up of bipolar with anxiety, nervous, restless, can't sit stil, akithisia?, smoking more, no psychosis and worries about finances and money’ 15's behavior tracking dated 9/2011 through May 2012 documents behaviors of pacing with a walker, inability to sit stil, attention seeking behavior, repetitive verbal distress and suspiciousness. These behaviors occurred 4 to 7 times in a 30 day period except November 2011 without any documented behaviors. that R15 uses psychotropic medications (Seroquel, Risperdal) related to disease process of seizures and dementia. R18's care plan included one intervention, "to administer medications as ordered. Monitor and document effects and effectiveness 16's Note to attending Physician dated 6/8/12 documents to "please evaluate for possible duplication of therapy.” The response on the note ‘Trazadone 25 mg at bedtime, Seroquel 100 mg at 15's care plan dated 7/1/11 documents for focus F 329 FORM CMS2507(02.99) Previous Versions Obsolete vet iD: BR35tt acy 1D Leo00600, ieontination sheet Page 19 of 28DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 Fe ‘ORM APPROVED OMB NO. 0938-0361 to attending physician form documents R15 has not been seen since 4/28/11 The facility's Psychopharmacological Drug Management program policy dated 10/2007 documents for antipsychotic use "summary charting must ocour quarterly, encompassing the reason for continued medication use, most recent dose reduction attempt and its result, any side effects noted and action taken, as well as the effectiveness of the medication, use this summary to objectively evaluate the continued need ofthis medication as well as to justify the use", Summarys were not presented by the facility and were not found in R18's record. The faxiliy’s policy documents for antipsychotics diagnosis alone does not warrant the use of antipsychotic medications. The clinical condition must meet at least one of the following criteria: auditory, visual or other hallucinations, the behavioral symptoms present a danger to self or | others. R15 did not have documented proof of those behaviors. The policy documents antipsychotic medications should not be used if the only indication is one or more of the following: | wandering, poor self care, restlessness, impaired memory, mild anxiety, fidgeting, nervousness or verbal expressions/behavior that are not due to | the indications listed above, and do not represent aa danger to the resident or others. (On 5/29/12 at 11:55 am, R15 was in the dining room feeding herself lunch, she made eye contact immediately and offered a pleasant greeting. On 5/24/12 at 10:30 a.m. R15 was walking in the halls with a walker alert and oriented speaking pleasantly to other residents in the hallway. STATEMENT OF DEFICIENCIES [(X1) PROVIDERISUPPLIERICLA | 0%) MULTIPLE CONSTRUCTION xs) ATE SURVEY {AND PLAN OF CORRECTION IDENTIFICATION NUMBER i aauea) (COMPLETED 148063 B.wNe 05/24/2012 TAME OF PROVIDER OR SUPPLIER ‘STREET ADORESS, CTY, STATE, ZIP CODE ‘308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 oa) “SUMMARY STATEMENT OF DEFIOENGES 1D PROVIDERS PLANOF CORRECTION] __ pa) PREF | (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (GACH CORRECTIVEACTION SHOULD BE | coMPuzron TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG. (OROSS-REFERENCED TO THE APPROPRIATE care DEFICIENCY) F 329] Continued From page 19 F329 FORM C€S-2567(02.0) Predous Valo Obsalela Event: BRS6it city 1D 5000600 If continuation sheat Page 20 of 28DEPARTMENT OF HEALTH AND HUMAN SERVICES, PRINTED: 07/07/2014 FORM APPROVED, CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 [StareweNT oF DEFICIENCIES xt) PROVERISUPPLERICLIA | (2) MULTIPLE CONSTRUCTION ox oaTE suRvEY JANO PLAN OF CORRECTION IDENTIICATIONNUMBER” |S aon. coMPuereD 146063 3.WING. 05/24/2012 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, GY, STATE, ZP CODE 308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 70 ‘SUMMARY STATENENT OF DEFICENGIES > PROVIDERS PLAN OF CORRECTION 7 PRErK | (EACH DEFICIENCY MUST BE PRECEDED BY FULL preeoe (EAGHOORRECTIVE ACTION SHOULD BE | conPuEnon AS REGULATORY OR LSC IDENTIFYING INFORMATION) Ae CROSS-REFERENCED TOTHE APPROPRIATE | ONE | DEFICIENCY) F 329] Continued From page 20 F 329 On 6/24/12 at 10:30 a.m. E2 stated that there was not any documentation in R18's chart for the Use of three antipsychotics and no behaviors as listed in the facility's poliey to warrant the use of three antipsychotics. E2 stated "she is better now since leaving the prior facility and the behaviors have decreased.” E2 stated R15 had not seen her psychiatrist since April of 2011. F 356 483.30(e) POSTED NURSE STAFFING F 356 er20rn2 88=C | INFORMATION ‘The facility must post the following information on a daily basis: | 0 Facility name. 0 The current date. (0 The total number and the actual hours worked by the following categories of licensed and | unlicensed nursing staff directly responsible for resident care per shift - Registered nurses. Licensed practical nurses or licensed vocational nurses (as defined under State law). | - Certified nurse aides. | o Resident census. “The facility must post the nurse staffing data | ‘specified above on a daily basis at the beginning of each shift. Data must be posted as follows: © Clear and readable format © Ina prominent place really accessible to residents and visitors. The facility must, upon oral or writen request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. The facility must maintain the posted daily nurse FORW CUS-2587(0290) Previous Versions Obese Event rBRa6Nt acy DL e000680| continuation sheet Page 21 of 28DEPARTMENT OF HEALTH AND HUMAN SERVICES, CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0394 [STATENENT OF DEFIGIENGES (XI) PROVIDERISUPPLIERICLA ‘AND PLAN OF CORRECTION. IDENTIFICATION NUMBER’ 146063 (22) MULTIPLE CONSTRUCTION ‘A BURDING oc) bare suRvEY (COMPLETED B.WING —. 05/24/2012 NANE OF PROVIDER OR SUPPLIER WALNUT MANOR ‘STREET ADOAESS, TTY, STATE, ZP CODE 308 SOUTH SECOND STREET WALNUT, IL 61376 SUMMARY STATENENT OF DEFIGIENCIES (GACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR USC IDENTIFYING INFORMATION) (0 PReex TAG 0. PROVIDERS FLAN OF CORRECTION PREFIK {GACH CORRECTIVE ACTION SHOULD BE TAS. (GROSS-REFERENCED TO THE APPROPRIATE. DEFICIENCY) 2, F 356] Continued From page 21 staffing data for a minimum of 18 months, or as required by State law, whichever is greater. This REQUIREMENT js not met as evidenced Based on observation, record review and interview, the facility failed to post staffing data regarding the number of licensed and unlicensed nursing staff directly responsible for resident care con each daily shift. Ths failure has the potential to offect all 57 residents, Findings include: (On 5/24/12 at 10:30 am, it was confirmed with ES that the Nurse Staffing Information was not posted for the following dates Friday, 5/18/12, Saturday 5/19/12, Sunday 5/20/12, and Monday 5/21/12 at the designated location on a ‘communal bulletin board near the nursing station, F9999 | FINAL OBSERVATIONS LICENSURE VIOLATIONS: 300.6108) 300.1210b) 300.1210d)6) 300.3240a) Section 300.610 Resident Care Policies a) The facility shall have written policies and procedures, governing all services provided by the facility which shall be formulated by a Resident Care Policy Committee consisting of at least the administrator, the advisory physician or the medical advisory committee and representatives of nursing and other services in F 356 Fo999| FORM CMS-2567(0299) Prevous Veins Oboes ‘Even IBRAGI! Fac TLe0c0800| If eontinuaton sheet Page 22 of 28DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0391 [STATEMENT OF DEFICIENCIES XI) PROVIDERISUPFLIERICLIA [AND PLAN OF CORRECTION. (02) MULTIPLE CONSTRUCTION Jos) DATE SURVEY the facility. These policies shall be in compliance with the Act and all rules promulgated thereunder. ‘These written policies shall be followed in operating the facility and shall be reviewed at least annually by this committee, as evidenced by ‘written, signed and dated minutes of such a meeting. Section 300.1210 General Requirements for Nursing and Personal Care ) The facility shall provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident, in accordance with each resident's comprehensive resident care plan. Adequate and properly supervised nursing care and personal care shall be provided to each resident to meet the total nursing and personal care needs of the resident. ) Pursuant to subsection (a), general nursing care shall include, at a minimum, the following and shall be practiced on a 24-hour, seven-day-a-week basis: 6) All necessary precautions shall be taken to | assure that the residents’ environment remains | as free of accident hazards as possible. All nursing personne! shall evaluate residents to see that each resident receives adequate supervision and assistance to prevent accidents. Section 300.3240 Abuse and Neglect 1a) An owner, licensee, administrator, employee or agent of a facility shall not abuse or neglect a resident. ‘These Requirements are NOT MET as IDENTIFICATION NUMBER: Sanna ‘COMPLE 146063, 8. WING osizano12 ‘NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, GITV, STATE, P CODE 308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 oD “SUMMARY STATEMENT OF DEFICENGIES D PROVIDERS PLAN OF CORRECTION 2) Prerx | (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (GACH CORRECTIVE ACTION SHOULD BE | coupterow TAG REGULATORY OR [SC IDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE one | DEFICIENCY). F9999 | Continued From page 22 Fa909| FORM CNS-2867(0200) Previous Versions Oveclet» EventID: BR2STT Feety 1D Le000600| If continuation shest Page 23 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0394 Evidenced by: Based on interview and record review, the facility failed to apply and monitor moist hot packs in a manner to prevent the development of a burn for ‘one of one resident (R1) who receive hot packs in the sample of 15. This failure resulted in Rt sustaining a two centimeter full thickness bum which required two months to heal Findings include: Nurses notes dated 02/27/12 (no time and noted a red broken blister area on R1's right shoulder. This circular area measured 2 centimeters. Nurses notes state that R1 sald "Therapy got that too hot, after they put a hot, ack on me Sat. (Saturday)" ‘The facility's Occurrence Report dated 02/27/12 and investigation dated 02/28/12 completed by 2 stated that "Upon conclusion of al interviews, including the resident." (R1) ‘received a 2 om. burn on her right shoulder from a hot pack placed con her Rt. (Fight) shoulder by therapy." This investigation includes documentation of an interview with E16 (Ccoupational Therapist), who stated that she had treated R1 on 02/24/12 after lunch and placed hot packs from the hydrocolator | on Rt’s right shoulder. E16's statement | documents that after 5 minutes into the treatment | R1 stated that "this is getting hot.” E16's | and the hot pack and placed a second towel down and replaced the pack. £16's statement says that when E16 removed the final hot pack, she (E16) noticed an area of redness and documented) state that a CNA was showering R1 | | statement documents that she removed the towel | [STATEMENT OF DEFICIENCIES (Kt) PROVIDERISUPPLIERICLIA | (2) MULTIPLE CONSTRUCTION o«s)DATE SURVEY JAND PLAN OF CORRECTION. IDENTIFICATION NUMBER: tannin) ‘CONPLETED 146063, 8. WING osiarzn12 NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CIV, STATE, ZP CODE 308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 10 “SUMMARY STATEMENT OF DEFIOENOES © ‘PROVIDERS PLAN OF CORRECTION Prerx | (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (GACH CORRECTIVE ACTION SHOULD 6 Tas REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (OROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} F9g99 | Continued From page 23, Fog90 | FORM OMS2867(0290) Previous Vasons Obeaeto vat ID: BR2SIT cy 1D L6008600| If contiuation chest Page 24 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0361 [STATEMENT OF DEFICIENCIES |X!) PROVIDERISUPPLIERICLIA | (2) MULTIPLE CONSTRUCTION Joc oaTE SURVEY [AND PLAN OF CORRECTION IDENTIFICATION NUWBER: anna (COMPLETED 146063 8. WING. = 05/24/2012 ANE OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, OV, STATE, 2P CODE 308 SOUTH SECOND STREET WALNUT MANOR WALNUT, IL 61376 pe ‘SUMMARY STATEMENT OF DEFICENCIES © PROVIDERS PLANOF CORRECTION] pa Prev | (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | coMeToN “Tas. REGULATORY OR LSC IDENTIFYING INFORMATION) TAG (OROSS-REFERENCED TO THE APPROPRIATE ore DEFICIENCY) F9999 | Continued From page 24 Fo990 moisture lke water on R's skin. E16's statement continues stating, "maybe | didnt drain al the ‘water off, 'm not sure why It got so hot." The facility's inservice information dated 02/29/12, states when applying moist heat packs to apply 4-6 layers of towels or 2 layers of commercial towels. Physician's order dated 02/27/12 instructed nurses to apply Silvadene cream to R1's burn twice daily. The facility's Wound Care Pian Treatment Plan dated 02/27/12 documents R1's ‘wound type as a burn on right shoulder, measuring 2 by 2 cm. The Patient Wound Care Order Sheet dated 03/01/2012 by the consulting wound nurse states that R1's burn wound is a full thickness wound and has increased to 2 by 2.5 ‘om. This documentation states that R1's wound bed is light brown/grey thin eschar, with thin fragile pink peri-wound tissue. ‘The Patient Wound Care Order Sheet dated 04/02/12 by the consulting wound nurse states that Rt's bum is 100% yellow brown slough with | thin pink fragile peri-wound tissue with a light purple discoloration 2 cm. perimeter. This form documents that the treatment for Rt was changed to an enzymatic debridement agent Santy with Hydrogel gauze to maintain a moist ‘wound environment with a bordered foam dressing to protect the frail, fragile tissue. The April 2012 Treatment Administration Record documents that R1's burn was healed and treatment discontinued on 04/23/12. (On 05/23/12 at 9:20 a.m., E2 confirmed that she had completed an investigation of R1's burn and FORM CMS 286710290) Pravous Vasions Obssite vent I BROETY Fae 0- 48000890 ‘continuation sheet Page 25 of 26DEPARTMENT OF HEALTH AND HUMAN SERVICES, CENTERS FOR MEDICARE & MEDICAID SERVICES PRINTED: 07/07/2014 FORM APPROVED OMB NO. 0938-0394 [STATEMENT OF DEFICIENCIES |X) PROVIDERSSUPPLIERICLIA _] 0) MALTIPLE CONSTRUCTION Jos) DATE SURVEY [AND PLAN OF CORRECTION IDENTIFIGATIONNUMBER’ | § auton COMPLETED 146063 Bawig 05/24/2012 Ta OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, GHY, STATE, ZP CODE 308 SOUTH SECOND STREET ee WALNUT, IL_ 61376 ma ‘SUNWARY STATEMENT OF DEFICIENCIES >] PROVIDERS PLAN OF CORRECTION 7 Pari | (GACH DEFICIENCY MUST BE PRECEDED EV FULL PREFIX (EACHCORRECTIVEAGTION SHOULD B= | couPteTon Tae REGULATORY OR LSC IDENTIFYING INFORMATION) Ae (CROSS REPERENCED 10 THE APPROPRIATE ome DEFICIENCY) F9999| Continued From page 25 F9999 determined that the cause of R's burn was from | the application of the hot packs. | (8) | FORO GMS 2s87(02-00) Previous Versone Obeoete Event OVBRIETT Feely 0 iL 6000600 continuation sheet Page 26 of 281 PH WALNUT MANOR: 18163792235 P a7 SJUN-20-2012 0¢ Walnut Manor Nursing Home 308 8, Second Street Walnut, llinis 61378 Combined Pian of Correction And Allegations of Compliance The fallowing plan of correction is not an admission to any of the alleged deficiencies and is Submitted at the request of the Itinols Department af Public Health (‘IDPH') Preparation and execution ofthis response and plan af correction does not constitute 4 admission or agreement by the provider as to the truth of the facts alleged or Conclusions set forth in the Statement of Deficiencies. The plan of correction le F187 Physician notification 1. The following corrective actions were taken immediately forthe affected Residents: * R10 and R14’s physician have bean notified ofthe cited weight loss. 10's physician had already been notified of the development of the of the new pressure ulcer. * Any new orders received have been implemented, * Siaff directly responsible for these oversights have been counseled, 2. Allresident’s experiencing a significant change in condition may be affected by the cited deficient practice. 3. The following measures have been taken to ensure the cited deficiency will not cour: Physician notification policy has been reviewed with all icensed staff * AMDA parameters for physician notification have been Implemented by nursing staff, * Utlization of a standardized physician communication and documentation Tool has been initiated. * Policies for weight management and Pressure Ulcer managemant have Reviewed, and revised as necessary. 4. To insure the remedies remain in place, the Director of Nursing or her designee Wil monitor acquisition of weights on all new admissions, ensuring that weekly weights are documented per policy, Physician notification of significant weight {086 will be monitored on @ case by case basis to ensure compliance, 5. Completion Date: June 20, 2012 wh Page 2of 9JUN-20-2012 04:31 PM HALNUT MANOR 18153792235, P, 6/11 Walnut POC June 2012 F258 Maintenance of Comfortable Sound levels 1, The following corrective action was taken’ immediately for the affected residents: + Weather stripping was placed around the door, 2, All residents on the 200 wing have the potential to be affected by failure to ‘maintain proper noise levels, 3. The following measures have been taken to ensure the cited deficiency will not reoccur: * Allstaff members have been in serviced to be mindful of using caution when closing doors in the building, * The Maintenance Director wil periodically check the door closures, 4 To ensure the remedies ramain in place the Social Services Director wil conduct fandom audits to ensure compliance, 5. Completion Date: June 20, 2012, ii Page 3 of 9SJUN-20-2012 04:31 PH WALNUT MANOR 18163792235 Pp. 6/II Walnut POC June 2012 F309 Pain assessment 1. “The following corrective actions were taken immediately forthe cited resident: * R's MAR was edited to refiect the need for pain level assessment with each scheduled medication administration * Nurses directly responsible for R2 were counseled regarding the change fo documentation and assessment expectation. * Ra's care plan was reviewed for accuracy and completeness, and any necessary revisions were made. ‘Al residents receiving pain medication have the potential to be affected by failure to monitor effectiveness (pain level) of the medication, ‘rhe following measures have been taken to ensure the cited defciency wil not reoccur: * Al Mcensed staf reviewed faciity expectations for pain assessment, evaluation and documentation, * Interdisciplinary team reviewed interdiscipinary approaches to chronic pain management. * Pharmacy was notified to change cieplay on MAR to reflect pain level assessment with each scheduled pain medication administration. To insure the remedies remain in place, the Director of Nursing or her designee will conduct random audits of medication administration records to erisure compliance with the facility standard, Completion Date: June 20, 2012 Page 40f 9JUN-20-2012 04:31 PH WALNUT MANOR 18153792235 Walnut POC June 2012 F314 Pressure Ulcers The following corrective actions were taken immediately for the cited resident: * A fresh dressing was immediately applied, per physician order, to R10's cited ulcer. * Ri0's physician was immediately notified of the resident's condition. No new orders were offered, * The licensed nurse responsible for documentation of R10's ulcer, and associated physician follow up has been counseled, * 10's care plan has been reviewed by the Interdisciplinary team, and revised to reflect current skin status, weight status and appropriate interventions, Allresidents at risk for pressure ulears have the potential to be affected by failure {o follow facility for ulcer prevention and management, ‘The following measures have been taken to ensure the cited: deficiency will not reoccur: * All licensed nurses have reviewed the facility ulcer prevention and treatment policy, and have demonstrated understanding of assessment and documentation expectations, Residents care plans for residents with pressure ulcers have been reviewed, and revised as necessary to reflact individualized approaches and specific goals, * All nursing assistants have been ‘educated regarding facility standard for ulcer care, and expectation that any missing dressings are reported to the nurse promptly for replacement. . Teinsure the remedies remsin in place, the director of Nursing ar her designee will conduct random audits of Ulcer treatmont records to ensure appropriate treatment and physician notfcation are being completed. Any deviation from Protocol that is identified will be remediated immediately. Completion Date: June 20, 2012 th Page 5 of 9 BLJUN-21-2012 03:50 PM = WALNUT MANOR 18153792235, Pasa Walnut POC June 2012 F823. Accidents 1. The following corrective actions were taken immedtately forthe cited resident: + At the time of the incident, R1's physician was notified of the injury. * Treatment was received for the injury, * Therapy contractor was notified of occurrence. + Therapy staff responsible for injury was removed from duty pending re-education on hot pack administration, 2. All residents receiving hot pack therapy have the potential to be affected by failure to property apply this modality. 3. The following measures have been taken to ensure the cited deficiency will not reoccur: + Only therapy staif are permitted to apply hot (hydrocolator) pack therapy. * All therapy staff assigned to this building have been re-educated on the use of heat modaities. * The therapy department has reviewed their policy/pracedure for the use of heat madaities, any revision deemed necessary have been made. ‘* Therapy staff have been in serviced on heat modality practice. 4, To insure the remedies remain in place, the therapy supervisor will conduct, random audits of hydrocolator pack administration to ensure compliance with the facility standard, 5. Completion Date: June 20, 2012 Page 6 of 9JUN-20-2012 04:31 PH WALNUT MANOR: 18163792235 PB S/il Walnut POC June 2012 F325 Weight Loss 1. The following corrective actions were taken immediately for the cited resident: '* Corporate dietician has reviewed the ‘weight records and treatment pian for R2, and made any appropriate recommendations regarding treatment plans, *R10's physician was notified of current status, including welght loss, current treatments, and development of a new pressure uicer + R10's care plan has been revised to reflect ‘specific interventions with measurable goals regarding ‘weight management. + Stal members responsible for deficit in assessment, notification and documentation of R10's Weight status have reviewed facility standards, and have been counseled regarding expected outcomes, * Note that as per facility policy we monitor weights weekly times 4 weeks, ‘Not weekly times 4 months as indicated in the 2567. ‘Alfesidents assessed at risk for weight loss have the potential to be affected by failure to moritor weight per policy, and actin accordance with their findings. The following measures have been taken to ensure the cited deficiency will not reoccur: * Weight management policies have been reviewed, and revised as hecessary by both nursing and dietary departments *+ Work flaw for obtaining rautine and admission weights has been reviewed with licensed, direct care, and dietary staff to ensure compliance with standard, as wall as interdisciplinary cooperation, * Cars plans for all residents who are identified as at risk for weight loss have been reviewed, and processes for routine care plans revision with changes in condition have been Implemented. Ze Insure the remedies remain in placa, the Director of Nursing or her designee and her designee and the dietary manager will conduct random audlis of weight ‘ecords and resident care plans to ensure compliance withthe facilty standard, Completion Date: June 20, 2012 NS Page 7 of 9JUN-21-2012 03:50 PM WALNUT MANOR 18153792235 Walnut POC June 2012 F329. Antipsychotics ib The following corrective actions wera taken immediately for the cited resident; + R15 has been seen by the psychiatrist, and all psycholpharmacological medications were reviewed in light of behaviors and known diagnoses, + Multiple medication reductions were accomplished + Evaluation of need, efficacy, and appropriateness was documented, *RiS's care plan has been revised to reflect specific reasons for medication use, and appropriate approaches to alleviate unwanted behaviors, All residents receiving antipsychotic medication have the potential to be affected by the cited practice, ‘The following measures have been taken to ensure the cited deficiency will not reoccur: * All licensed staff have been re-educated regarding appropriate utilization Of antipsychotics, including but not limited to qualifying diagnoses, reduction requirements, and non pharmacologic approaches for behavior management. * A licensed psychiatrist has been secured to manage antipsychotic use in the facility, * Quarterly psychopharmacologic reviews have been reviewed, and staff competency refreshed. * Care plans for all residents have been reviewed to ensure appropriate utilization and approaches are documented, * Policies regarding utilization of psychopharmacological medications including antipsychotic indications, use, side effects and dose reductions have been reviewed and revised as necessary, * Licensed staff has received copies of the appropriate policy. To insure the remedies remain in place the consultant pharmacist and Director of Nursing will conduct random audits of behavior recards to ensure compliance with the facility standard, Completion Date: June 20, 2012 Page 8 of 9 PBSUN-21-2012 03:50 PH WALNUT MANOR 18163792236 Walnut POC June 2012 F388 Staff Posting ‘The following corrective actions were taken immediately. * Correct staffing levels were determined, and appropriate documentation was posted per regulation. All interested parties have the potential to be affected by the failure ta post facility staffing per regulation The following measures have been taken to ensure the cited deficiency will not reoccur: * Regulation was reviewed by DON, Administrator, and other administrative nurses, * Aback up plan for Posting in the DON's absence was established, and all affected parties notified, * Polley for staff posting was reviewed and revised to Include the assignment of alternative staff responsible in the absence of the DON. To insure the remedies remain in place, the administrator will conduct weekly audits of staff posting to ensure compliance with the facility standard, Completion Date: June 20, 2012 Page 9 of 9