04.01.11 columbus manor

8/4/2019 04.01.11 Columbus Manor

1/11

A. BUILDING

(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X3) DATE SURVEYCOMPLETED

PRINTED: 04/12/20FORM APPROV

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

______________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-03

14E147 04/01/2011

C

CHICAGO, IL 60644

STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

COLUMBUS MANOR RES CARE HOME5107 21 WEST JACKSON BOULEVARD

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

F 000 INITIAL COMMENTS F 000

COMPLAINT INVESTIGATION# 1180880 / IL 52264

An extended survey was conducted.

F 323

SS=K

483.25(h) FREE OF ACCIDENTHAZARDS/SUPERVISION/DEVICES

The facility must ensure that the residentenvironment remains as free of accident hazardsas is possible; and each resident receivesadequate supervision and assistance devices toprevent accidents.

This REQUIREMENT is not met as evidencedby:

F 323

Based on observation, interview and recordreview the facility failed to provide supervisonand monitor 1 out of 4 sampled residents R1,identified with a history of smoking. This failureto monitor/supervise this resident resulted in thisresident setting fires in four rooms in the facility (two beds & two closets) with his cigarette lighterand as a result of the one of these fires R2, wastransported to the hospital for evaluation ofsmoke inhalation and R3 was transferred due toa burn to her lower extremity.

The facility ' s smoking policy and proceduredoes not include how smoking materials

/paraphernalia such as matches and lighters willbe handled when resident is noncompliant.

These failures resulted in an ImmediateJeopardy.

ABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

ny deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined thatther safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

ollowing 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 14ays following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continuedrogram participation.

ORM CMS-2567(02-99) Previous Versions Obsolete 5GF011Event ID: Facility ID: IL6001994 If continuation sheet Page 1 o


2/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG



F 323 Continued From page 1 F 323

These failures occurred for two out of fivebuildings, the #33 building and #15 building in thefacility.

E1 (Administrator) and E4(Social ServicesDirector) were notified of the Immediate Jeopardyon April 1, 2011 at 11:45AM. The ImmediateJeopardy was determined to have begun March18, 2011 at 4:15AM when R1 started four fireswith his lighter in different location(Bldgs#15!) throughout the facility causing harm totwo residents, R2 and R3 and putting at risk thehealth, safety and welfare of the residents in thefacility that reside in those buildings.

Findings include:

On 3/18 /11 at 12:00pm E1 (Administrator) saidthat he was notified at home by telephone via E4(Social Service Director) that there was fire at thefacility.

According to the facility ' s incident report formdated March 18, 2011, location of fire Building5115(#15) -Room 5, Building 5133(#33)-Rooms1, 5, and 7.A fire incident took place approximately 4:15amon March 18, 2011 ... ... .....Z1 (Fire Dept) and Z2(Police Dept) arrived on scene at approximately4:20am. Police bomb and Arson squad memberswere called and investigated the incident.R2 was transported to Z3 (hospital) for smokeinhalation. R3 was treated at Z3 (hospital) for aminor burn to the right leg.

R1 was questioned at the facility by the Z4(Bomb and Arson) and admitted to setting four(4) isolated fires in the rooms stated above. R1was transported to Z5 (police station) for



3/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG




processing.

Per interview with E4(Social Service Director) on3-18-2011 at 10AM she said she punched in at3:46AM went to the social service office and at4:00AM she heard a " ding ding " sound of thefire alarm. She stated when she first heard thesound she thought it was aFire drill and she stepped out of her office andinto the corridor. She said she saw R5 whoresides in 33-7 running down the hall yellingthere ' s a " fire, " she said she got the threeCNA ' s (certified nurse ' s assistant) that were inthe nursing office and went to 33-1 with the fireextinguisher to put out the mattress that wasaflame. She stated that she thought that wasthe only fire, then she heard another resident, R4saying " E4 it ' s upstairs. " She said that shewent upstairs and the hallway was covered insmoke, I can ' t see and I can ' t breathe. Shesaid she did not know fire was in #15-5.

On 3/18/11 at approximate 10:45AM with E3(Assistant Administrator) toured thefire/smoke/water damaged area. E3 said thebuildings are numbered and connected by acorridor and there is an up and down, or 2 floors.Building 15 -Room 5 was observed to haveexcess water on the floor; black soot was on thewall. E3 said the mattress belonging to R2, themattress was moved out of the room to bediscarded. E3 said the privacy curtain wasburned.The outside patio area contained a burnedmattress, bags of personal clothing and articles

that had been damaged by smoke or water fromthe sprinklers per E3.Building 33-Room1 was the only roomunoccupied at the time according to E3.



4/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG




She stated areas 15-5, 33-5 and 33-7 hadresidents residing in these rooms.All four rooms 15-5, 33-1, 33-5 and 33-7 were nothabitable at the time of observation and theresidents were all in the large main dining room.There was excess water on the floor from thesprinklers and housekeeping staff were observedusing a water evacuation shop vacuums andwiping down the walls.On 3/18/11, E3 said that R1 had been taken bythe Z2 Department and would later be taken tothe hospital for psychiatric evaluation. R1 wasunavailable for observation or interview on3/18/11 and 04/01/11. E3 said that no otherresidents other R2 and R3 were sent out to thehospital related to fire. E3 said that R1 had roommates who are still in the facility.

Nurse's note dated 3-18-2011 at 9AM residentvery agitated and angry telling staff that he setthe fire in the rooms because he wanted to kill

people. Resident was given 5mg of haldol hetaken willingly. Then resident was taken nextdoor where he was talking to the fire inspector.3-18-2011 at 9:20am resident was escorted tothe police station by the police.Resident had no compklaints of pain ordiscomfort T-98.2,P-80, R-20,BP-138/76According to R1's clinical record R1 was lastassessed for smoking safety risk on 02/10/2011.R1 was also assessed to be safely following thefacility's safe smoking policy. The assessmentindicates that R1 has no history of hazardous andinappropriate behaviors. A review of R1's plan

of care indicated that R1 was assessed to haveimpaired judgment related to his mental illness.E4 (social service) could not recall R1 beingobserved smoking in inappropriate places at any



5/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG




time. On 03/18/ 2011, E4 said that staff isrequired to make rounds every 2 hours, tomonitor residents. E4 said that residentsassessed for inappropriate smoking are listed onthe facility's smoking program. A document titled,Passed Cigarette Program was provided tosurveyor. E4 said that R1 is not on the smokingprogram list. If on the list, E4 said residents arenot allowed to have smoking material on theirperson to include cigarettes, matches, andlighters. E4 said that residents are assessed forsmoking safety risk at admission, annually, andquarterly.

E9 (psychosocial rehabilitation aide) on03/18/2011 said that he has been assigned to R1for 2 years. E9 said that R1 goes out into thecommunity on pass, at times. E9 explained thatthe facility smoking program is for residents thatare assessed or observed to have unsafesmoking behaviors or smoke in inappropriateplaces.

He said R1 was not one of those residents.

On 03/18/2011 at 11:30AM , R4 stated that hewas sleeping in room #33-8, then he heardsmoke alarm. He walked out into hallway andsaw smoke coming out of #33-5, then I went totell somebody. I told E4( Social Service Director),then I went to the cafeteria.

On 04/01/11 at 6:15AM via telephone E5(certified nurse ' s aide), said that she heard ading-dong and stepped out in hallway and sawE4 in hallway and a resident yelling there ' s a

fire. E4 then told her to help with the evacuationof the residents to the dining room. E5 was askedif she went into any rooms, she replied " No " ;she concentrated on getting residents to the



6/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG




dining room...

Nurse 's s note dated 03/18 /2011, R2 was sentto Z3 (hospital emergency room) at 4:30AM via911. Note at 11AM -R2 was admitted to thehospital was diagnosed with smoke inhalationand dementia. R2 was not available forobservation or interview during onsite visits to thefacilityNurse's note dated 3-18-2011 at 940AMResident#3 has orders to be sent out to Z3hospital to be evaluated for burn to Rt. innercalves. Resident is not complaining at this time..........Resident was asked how did this happenshe stated I don't know Resident was transportedby ambulance to Z3 emergency room..

The facility Smoking policy and procedure doesNOT mention and include under noncompliancewith the smoking policy a restriction on access tosmoking materials/paraphernalia such as lightersand matches.. According to the facility's smoking

policy -Noncompliance with the facility smoking policyresults in the following:Resident is assessed and found to be " at risk "the resident will be required to take part in thefacility passed smoking program. Resident ispassed two cigarettes every two hours,supervised by the facility staff. Program begins at7am and ends at 10pm as scheduled. Allsmoking times are posted the activity office aswell as at the front desk.

The policy states that a smoking safety risk

assessment is done within 72 hours ofadmission. There is no mention that additionalassessments will be done quarterly, annually orafter an observation/ incident.



7/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG




The Immediate Jeopardy was removed on April1, 2011 at 7 PM. The facility still remains out ofcompliance at a Severity and Scope- Level 2because of the need to allow for the facility tocomplete staff training and Nursing in-services,and to evaluate the effectiveness of the revisedpolicies/ protocols/ monitoring and assessmentfor inappropriate smoking behaviors and careplan updates.

The facility provided the following removal plan:

1.At approximately 4am on March 18, 2011,Resident R1 lit fire to 4 rooms in the facility. Atthe onset of the fires, alarms and sprinklersystems were activated. Residents wereevacuated the dining room by staff on duty. OnMarch 18, 2011, Resident (R1) was questionedat the facility by the Chicago Bomb and ArsonDepartment and admitted to setting four isolatedfires in rooms 33-1, 33-5, 33-7, and 15-5.

2.Resident R1 was transported to District 15 forprocessing, then to Hospital were he was serveda 30 day notice. Resident RM has beed chargedwith 4 counts of arson and will not be returning tothe facilityResident R2 was transported to Hospital forsmoke inhalation.Resident R3 was treated at Hospital for a 2nddegree burn to her right leg.3.On April 1, 2011, an in-service on FirePreparedness and the Fire Evacuation Policy andProcedure for all staff began under the directionof Assistant Administrator. All staff in-services will

be completed by April 8, 2011 and on-going. Thiswill be overseen by the Administrator andMaintenance Supervisor. CNAs will continuemaking hourly rounds to rooms. 4.Social Service



8/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG




Director and Consultant will in-service all staffmembers on behavioral warning signs (includingmild changes).The Social Service Department will complete aBehavioral System Evaluation on all residents inthe facility which will be updated quarterly or asneeded. Evaluation completion by April 8, 2011and ongoing.Any behavioral changes will be addressed withthe residents ' physician and brought to theattention of the nursing department. Residentswill be care planned accordingly.5.An in-service, directed by the Social ServiceDepartment and Maintenance Department, for allresidents regarding fire alarm protocol andevacuation procedures will be completed by April8, 2011 and on-going. This will be overseen bythe Administrator and Maintenance Supervisor.6.The Fire Safety Program will be evaluated atthe next scheduled quarterly Quality Assurancemeeting. This will be an on-going process toevaluate, maintain and improve the process.

Fire Safety System & Fire Preparedness and FireEvacuation Policy and Procedure are attached. Inaddition to the quarterly fire drills, more frequentfire drills will be performed on all three shifts.Fire drill was conducted on the 12m to 8am shifton March 30, 2011. Fire Drill Record and sign-insheet attached

F 518

SS=F

483.75(m)(2) TRAIN ALL STAFF-EMERGENCYPROCEDURES/DRILLS

The facility must train all employees inemergency procedures when they begin to workin the facility; periodically review the procedures

with existing staff; and carry out unannouncedstaff drills using those procedures.

F 518



9/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG




This REQUIREMENT is not met as evidencedby:Based on interview and record review the facilityfailed to have staff properly trained in firedisaster preparedness and the facility failed tofollow their fire disaster policy and procedure.This failure has the potential to affect all the 119residents in the facility.

Findings include:

According to Policy entitled Fire EvacuationPolicy and Procedure# 1 Reception /Security Guard shall make anannouncement that the fire alarm has gone offand state the location of thefire(wing,floor,building, or potential location) sothat the team lead or manager on duty can directthe staff where to search for the fire andevacuate residents.

According to the facility' s incident report form

dated March 18, 2011, location of fire Building5115(#15) -Room 5, Building 5133(#33)-Rooms1, 5, and 7.A fire incident took place approximately 4:15amon March 18, 2011 ... ... .....Z1 (Fire Dept) and Z2(Police Dept) arrived on scene at approximately4:20am. Police bomb and Arson squad memberswere called and investigated the incident.R2 was transported to Z3 (hospital) for smokeinhalation. R3 was treated at Z3 (hospital) for aminor burn to the right leg.R1 was questioned at the facility by the Z4(Bomb and Arson) and admitted to setting four

(4) isolated fires in the rooms stated above. R1was transported to Z5 (police station) forprocessing.



10/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG




Per interview with E4(Social Service Director) on3-18-2011 she said she punched in at 3:46AMwent to the social service office and at 4:00AMshe heard a " ding ding " sound of the firealarm. She stated when she first heard the soundshe thought it was aFire drill and she stepped out of her office andinto the corridor. She said she saw R5 whoresides in 33-7 running down the hall yellingthere ' s a " fire, " she said she got the threeCNA ' s (certified nurse ' s assistant) and went to33-1 with the fire extinguisher to put out themattress that was aflame. She stated that shethought that was the only fire, then she heardanother resident, R4 saying " E4 it ' s upstairs. "She said that she went upstairs and the hallwaywas covered in smoke, can ' t see and can ' tbreathe. She said she did not know fire was in#15-5.

On 3/18/11 at approximate 10:45AM with E3(Assistant Administrator) toured the

fire/smoke/water damaged area. E3 said thebuildings are numbered and connected by acorridor and there is an up and down, or 2 floors.Building 15 -Room 5 was observed to haveexcess water on the floor; black soot was on thewall. E3 said the mattress belonging All the foursrooms had excess water soaking the floors dueto the sprinklers activating.to R2, the mattresswas moved out to discard. E3 said the privacycurtain was burned.

Interviews with E#4 on 03-18-2011 and E#5 andE#6 on 04-01-11 all revealed that item #1 was

not done. None of these staff knew that therewas an actual fire.

On 04/01/11 at 6:15AM via telephone E5



11/11

A. BUILDING






B. WING _____________________________

______________________



14E147 04/01/2011

C

CHICAGO, IL 60644





(X5)COMPLETI

DATE

IDPREFIX

TAG

(X4) IDPREFIXTAG




(certified nurse ' s aide), said that she heard ading-dong and stepped out in hallway and sawE4 in hallway and a resident yelling there ' s afire. E4 then told her to help with the evacuationof the residents to the dining room. E5 was askedif she went into any rooms, she replied " No " ;she concentrated on getting residents to thedining room...E6(certified nurse's aide) stated on 04-01-2011 at6:35AM via telephone that she was in the nursingoffice the day of the fires and she heard E4instruct them to evacuate the residents. She saidshe heard a resident ,R5 saying there is a fire.She stated she heard the ding-ding alarm.


04.01.11 columbus manor

Documents