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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 COMPLAINT INVESTIGATION # 1180880 / IL 52264 An extended survey was conducted. F 323 483.25(h) FREE OF ACCIDENT SS=K 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 000

F 323

This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to provide supervison and monitor 1 out of 4 sampled residents R1, identified with a history of smoking. This failure to monitor/supervise this resident resulted in this resident setting fires in four rooms in the facility ( two beds & two closets) with his cigarette lighter and as a result of the one of these fires R2, was transported to the hospital for evaluation of smoke inhalation and R3 was transferred due to a burn to her lower extremity. The facility ' s smoking policy and procedure does not include how smoking materials /paraphernalia such as matches and lighters will be handled when resident is noncompliant. These failures resulted in an Immediate Jeopardy.
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: 5GF011

Facility ID: IL6001994

If continuation sheet Page 1 of 11

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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 1 These failures occurred for two out of five buildings, the #33 building and #15 building in the facility. E1 (Administrator) and E4(Social Services Director) were notified of the Immediate Jeopardy on April 1, 2011 at 11:45AM. The Immediate Jeopardy was determined to have begun March 18, 2011 at 4:15AM when R1 started four fires with his lighter in different location(Bldgs #15&#33) throughout the facility causing harm to two residents, R2 and R3 and putting at risk the health, safety and welfare of the residents in the facility that reside in those buildings. Findings include: On 3/18 /11 at 12:00pm E1 (Administrator) said that he was notified at home by telephone via E4 (Social Service Director) that there was fire at the facility. According to the facility ' s incident report form dated March 18, 2011, location of fire Building 5115(#15) -Room 5, Building 5133(#33)-Rooms 1, 5, and 7. A fire incident took place approximately 4:15am on March 18, 2011 ... ... .....Z1 (Fire Dept) and Z2 (Police Dept) arrived on scene at approximately 4:20am. Police bomb and Arson squad members were called and investigated the incident. R2 was transported to Z3 (hospital) for smoke inhalation. R3 was treated at Z3 (hospital) for a minor 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. R1 was transported to Z5 (police station) for
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: 5GF011

Facility ID: IL6001994

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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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 2 processing. Per interview with E4(Social Service Director) on 3-18-2011 at 10AM she said she punched in at 3:46AM went to the social service office and at 4:00AM she heard a " ding ding " sound of the fire alarm. She stated when she first heard the sound she thought it was a Fire drill and she stepped out of her office and into the corridor. She said she saw R5 who resides in 33-7 running down the hall yelling there ' s a " fire, " she said she got the three CNA ' s (certified nurse ' s assistant) that were in the nursing office and went to 33-1 with the fire extinguisher to put out the mattress that was aflame. She stated that she thought that was the only fire, then she heard another resident, R4 saying " E4 it ' s upstairs. " She said that she went upstairs and the hallway was covered in smoke, I can ' t see and I can ' t breathe. 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 the buildings are numbered and connected by a corridor and there is an up and down, or 2 floors. Building 15 -Room 5 was observed to have excess water on the floor; black soot was on the wall. E3 said the mattress belonging to R2, the mattress was moved out of the room to be discarded. E3 said the privacy curtain was burned. The outside patio area contained a burned mattress, bags of personal clothing and articles that had been damaged by smoke or water from the sprinklers per E3. Building 33-Room1 was the only room unoccupied at the time according to E3.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: 5GF011

Facility ID: IL6001994

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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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 3 She stated areas 15-5, 33-5 and 33-7 had residents residing in these rooms. All four rooms 15-5, 33-1, 33-5 and 33-7 were not habitable at the time of observation and the residents were all in the large main dining room. There was excess water on the floor from the sprinklers and housekeeping staff were observed using a water evacuation shop vacuums and wiping down the walls. On 3/18/11, E3 said that R1 had been taken by the Z2 Department and would later be taken to the hospital for psychiatric evaluation. R1 was unavailable for observation or interview on 3/18/11 and 04/01/11. E3 said that no other residents other R2 and R3 were sent out to the hospital related to fire. E3 said that R1 had room mates who are still in the facility. Nurse's note dated 3-18-2011 at 9AM resident very agitated and angry telling staff that he set the fire in the rooms because he wanted to kill people. Resident was given 5mg of haldol he taken willingly. Then resident was taken next door where he was talking to the fire inspector. 3-18-2011 at 9:20am resident was escorted to the police station by the police. Resident had no compklaints of pain or discomfort T-98.2,P-80, R-20,BP-138/76 According to R1's clinical record R1 was last assessed for smoking safety risk on 02/10/2011. R1 was also assessed to be safely following the facility's safe smoking policy. The assessment indicates that R1 has no history of hazardous and inappropriate behaviors. A review of R1's plan of care indicated that R1 was assessed to have impaired judgment related to his mental illness. E4 (social service) could not recall R1 being observed smoking in inappropriate places at any
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: 5GF011

Facility ID: IL6001994

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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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 4 time. On 03/18/ 2011, E4 said that staff is required to make rounds every 2 hours, to monitor residents. E4 said that residents assessed for inappropriate smoking are listed on the facility's smoking program. A document titled, Passed Cigarette Program was provided to surveyor. E4 said that R1 is not on the smoking program list. If on the list, E4 said residents are not allowed to have smoking material on their person to include cigarettes, matches, and lighters. E4 said that residents are assessed for smoking safety risk at admission, annually, and quarterly. E9 (psychosocial rehabilitation aide) on 03/18/2011 said that he has been assigned to R1 for 2 years. E9 said that R1 goes out into the community on pass, at times. E9 explained that the facility smoking program is for residents that are assessed or observed to have unsafe smoking behaviors or smoke in inappropriate places. He said R1 was not one of those residents. On 03/18/2011 at 11:30AM , R4 stated that he was sleeping in room #33-8, then he heard smoke alarm. He walked out into hallway and saw smoke coming out of #33-5, then I went to tell 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 a ding-dong and stepped out in hallway and saw E4 in hallway and a resident yelling there ' s a fire. E4 then told her to help with the evacuation of the residents to the dining room. E5 was asked if she went into any rooms, she replied " No " ; she concentrated on getting residents to the
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: 5GF011

Facility ID: IL6001994

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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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 5 dining room... Nurse 's s note dated 03/18 /2011, R2 was sent to Z3 (hospital emergency room) at 4:30AM via 911. Note at 11AM -R2 was admitted to the hospital was diagnosed with smoke inhalation and dementia. R2 was not available for observation or interview during onsite visits to the facility Nurse's note dated 3-18-2011 at 940AM Resident#3 has orders to be sent out to Z3 hospital to be evaluated for burn to Rt. inner calves. Resident is not complaining at this time. .........Resident was asked how did this happen she stated I don't know Resident was transported by ambulance to Z3 emergency room.. The facility Smoking policy and procedure does NOT mention and include under noncompliance with the smoking policy a restriction on access to smoking materials/paraphernalia such as lighters and matches.. According to the facility's smoking policy Noncompliance with the facility smoking policy results in the following: Resident is assessed and found to be " at risk " the resident will be required to take part in the facility passed smoking program. Resident is passed two cigarettes every two hours, supervised by the facility staff. Program begins at 7am and ends at 10pm as scheduled. All smoking times are posted the activity office as well as at the front desk. The policy states that a smoking safety risk assessment is done within 72 hours of admission. There is no mention that additional assessments will be done quarterly, annually or after an observation/ incident.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: 5GF011

Facility ID: IL6001994

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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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 6 The Immediate Jeopardy was removed on April 1, 2011 at 7 PM. The facility still remains out of compliance at a Severity and Scope- Level 2 because of the need to allow for the facility to complete staff training and Nursing in-services, and to evaluate the effectiveness of the revised policies/ protocols/ monitoring and assessment for inappropriate smoking behaviors and care plan 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. At the onset of the fires, alarms and sprinkler systems were activated. Residents were evacuated the dining room by staff on duty. On March 18, 2011, Resident (R1) was questioned at the facility by the Chicago Bomb and Arson Department and admitted to setting four isolated fires in rooms 33-1, 33-5, 33-7, and 15-5. 2.Resident R1 was transported to District 15 for processing, then to Hospital were he was served a 30 day notice. Resident RM has beed charged with 4 counts of arson and will not be returning to the facility Resident R2 was transported to Hospital for smoke inhalation. Resident R3 was treated at Hospital for a 2nd degree burn to her right leg. 3.On April 1, 2011, an in-service on Fire Preparedness and the Fire Evacuation Policy and Procedure for all staff began under the direction of Assistant Administrator. All staff in-services will be completed by April 8, 2011 and on-going. This will be overseen by the Administrator and Maintenance Supervisor. CNAs will continue making hourly rounds to rooms. 4.Social Service
FORM CMS-2567(02-99) Previous Versions Obsolete

F 323

Event ID: 5GF011

Facility ID: IL6001994

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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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 7 Director and Consultant will in-service all staff members on behavioral warning signs (including mild changes). The Social Service Department will complete a Behavioral System Evaluation on all residents in the facility which will be updated quarterly or as needed. Evaluation completion by April 8, 2011 and ongoing. Any behavioral changes will be addressed with the residents ' physician and brought to the attention of the nursing department. Residents will be care planned accordingly. 5.An in-service, directed by the Social Service Department and Maintenance Department, for all residents regarding fire alarm protocol and evacuation procedures will be completed by April 8, 2011 and on-going. This will be overseen by the Administrator and Maintenance Supervisor. 6.The Fire Safety Program will be evaluated at the next scheduled quarterly Quality Assurance meeting. This will be an on-going process to evaluate, maintain and improve the process. Fire Safety System & Fire Preparedness and Fire Evacuation Policy and Procedure are attached. In addition to the quarterly fire drills, more frequent fire drills will be performed on all three shifts. Fire drill was conducted on the 12m to 8am shift on March 30, 2011. Fire Drill Record and sign-in sheet attached F 518 483.75(m)(2) TRAIN ALL STAFF-EMERGENCY SS=F PROCEDURES/DRILLS The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures.

F 323

F 518

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

Event ID: 5GF011

Facility ID: IL6001994

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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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 518 Continued From page 8 This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to have staff properly trained in fire disaster preparedness and the facility failed to follow their fire disaster policy and procedure. This failure has the potential to affect all the 119 residents in the facility. Findings include: According to Policy entitled Fire Evacuation Policy and Procedure # 1 Reception /Security Guard shall make an announcement that the fire alarm has gone off and state the location of the fire(wing,floor,building, or potential location) so that the team lead or manager on duty can direct the staff where to search for the fire and evacuate residents. According to the facility' s incident report form dated March 18, 2011, location of fire Building 5115(#15) -Room 5, Building 5133(#33)-Rooms 1, 5, and 7. A fire incident took place approximately 4:15am on March 18, 2011 ... ... .....Z1 (Fire Dept) and Z2 (Police Dept) arrived on scene at approximately 4:20am. Police bomb and Arson squad members were called and investigated the incident. R2 was transported to Z3 (hospital) for smoke inhalation. R3 was treated at Z3 (hospital) for a minor 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. R1 was transported to Z5 (police station) for processing.
FORM CMS-2567(02-99) Previous Versions Obsolete

F 518

Event ID: 5GF011

Facility ID: IL6001994

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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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 518 Continued From page 9 Per interview with E4(Social Service Director) on 3-18-2011 she said she punched in at 3:46AM went to the social service office and at 4:00AM she heard a " ding ding " sound of the fire alarm. She stated when she first heard the sound she thought it was a Fire drill and she stepped out of her office and into the corridor. She said she saw R5 who resides in 33-7 running down the hall yelling there ' s a " fire, " she said she got the three CNA ' s (certified nurse ' s assistant) and went to 33-1 with the fire extinguisher to put out the mattress that was aflame. She stated that she thought that was the only fire, then she heard another resident, R4 saying " E4 it ' s upstairs. " She said that she went upstairs and the hallway was covered in smoke, can ' t see and can ' t breathe. 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 the buildings are numbered and connected by a corridor and there is an up and down, or 2 floors. Building 15 -Room 5 was observed to have excess water on the floor; black soot was on the wall. E3 said the mattress belonging All the fours rooms had excess water soaking the floors due to the sprinklers activating.to R2, the mattress was moved out to discard. E3 said the privacy curtain was burned. Interviews with E#4 on 03-18-2011 and E#5 and E#6 on 04-01-11 all revealed that item #1 was not done. None of these staff knew that there was an actual fire. On 04/01/11 at 6:15AM via telephone E5
FORM CMS-2567(02-99) Previous Versions Obsolete

F 518

Event ID: 5GF011

Facility ID: IL6001994

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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: 04/12/2011 FORM APPROVED

OMB NO. 0938-0391

(X3) DATE SURVEY COMPLETED

______________________

14E147
NAME OF PROVIDER OR SUPPLIER

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

C 04/01/2011

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 518 Continued From page 10 (certified nurse ' s aide), said that she heard a ding-dong and stepped out in hallway and saw E4 in hallway and a resident yelling there ' s a fire. E4 then told her to help with the evacuation of the residents to the dining room. E5 was asked if she went into any rooms, she replied " No " ; she concentrated on getting residents to the dining room... E6(certified nurse's aide) stated on 04-01-2011 at 6:35AM via telephone that she was in the nursing office the day of the fires and she heard E4 instruct them to evacuate the residents. She said she heard a resident ,R5 saying there is a fire. She stated she heard the ding-ding alarm.

F 518

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

Event ID: 5GF011

Facility ID: IL6001994

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