Inspection visit

InspectionNovember 22, 2022

PITTSFIELD MANORCMS #14583720 citations on this visit

20 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 20 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R151's Nurse's Note, dated 10/28/2022 on 3:55 PM, documents, Resident has been attempting to exit memory lane doors this shift. She has been taken for walks and has participated with activities with staff this afternoon. At this time resident was being redirected away from doors by CNA (Certified Nurse Assistant) when laundry staff came through the doors resident turned around and lost her balance falling to the floor hitting her Rt (right) eyebrow on the handrail. Resident has a small laceration with a hematoma noted on Rt elbow bleeding stopped area cleansed and dry drsg (dressing) applied. Resident continues to c/o (complaint) of Rt (right) wrist pain MD (medical doctor) informed with orders rec'd (received) for portable 3 view Rt wrist X-ray. Test ordered from biotech at this time. Residents Affected - Few R151's Nurse's Note, dated 10/29/2022 at 12:00 AM, documents, Resident had been sitting in chair in room, stating she can't walk because her right wrist hurt. Resident was able to walk without difficulty to bathroom with stand by assist. Resident continues with hematoma and bruising to right eyebrow line and eye. Small amount of blood noted at times after resident rubs area. PRN (as needed) Tylenol given for pain. Resident does move right wrist noted it hurts when she tries to grip items or lift items with hand. Currently resting quietly in bed. R151's Nurse's Note, dated 10/29/2022 at 10:00 AM, documents, This nurse confirmed x-ray order with (X-ray Company) and representative stated they did not have a tech (technician) for our area today and they would not be able to come to facility. Notified Nurse Practitioner and order was given to send by ambulance to ED (Emergency Department)/resident refusing to ambulate & c/o (complaint of) pain when attempting to use or grasp anything with right hand. R151's Nurse's Note, dated 10/29/2022 at 12:17 PM, documents, Nurse ED notified facility that resident would be returning with ortho (orthopedic) cast/fracture/right wrist. DON notified & stated she would notify administrator. R151's Hospital Disposition, dated 10/29/22, documents, Discharge DX (diagnosis). Closed fracture of distal end of right radius. On 11/16/22 at 12:08 PM, V19, Licensed Practical Nurse (LPN), stated, She (151) had been at the doors banging on them to get out. The CNA got her redirected and walking away from the doors. Then staff tell me that she has fallen. When I got there, she was on her bottom, sitting up against the wall. She did not complain of pain at all. I assessed her and got her back to her room. Once back in the room she complained of pain of the wrist. There was no swelling or bruising. She continued to complain of wrist pain but no hip pain. Her leg did not have any rotation or shortening. I ordered a STAT (immediately) wrist X-ray. I did not realize that the X-ray had not been done because I was off for a bit after the shift on 10/28/22. If (the mobile X-ray company) had not come for me in a timely (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 145837 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 manner, I would have called the company and found out what is going on and if they couldn't come, I would have called the doctor and gotten an order to send her to the Emergency Room. Level of Harm - Actual harm Residents Affected - Few On 11/16/22 at 3:45 PM, V14, LPN, stated, I took care of her (R151) after her first fall (10/29/22). I realized that (X-ray company) did not come for her wrist, I called them, and they said that they did not have a technician available. I called the doctor and got an order to send her to the ER (Emergency Room). When I called report to the ER, I told them she was having pain in her wrist and pain with standing. I was not sure if the difficulty with standing was from her wrist because she would use it to pull up or if it was her hip. The hospital just did a wrist X-ray not a hip X-ray. She just held her wrist and complained of pain. She didn't complain of hip pain for me. R151's Face Sheet, undated, documents that R151 was admitted on [DATE] and has diagnoses of Alzheimer's Disease and Fracture Carpal Bone of right wrist. R151's MDS, dated [DATE] documents R151 is severely cognitively impaired. On 11/21/22 at 11:30 AM, V1, Administrator, stated that she expects X-rays to be done timely and if not to call the doctor and get and order to send the resident out to the hospital. Based on interview and record review the facility failed to provide timely treatment of a fall with suspected fracture for 2 of 12 residents (R32, R151) in a sample of 33. This resulted in R32 going 2 days without treatment of her fractured elbow and R151 not receiving a timely Xray for a right wrist fracture. Findings include: 1. R32's diagnoses include Age-related osteoporosis without current pathological fracture, Pain in right elbow, unspecified fracture of shaft of right ulna, subsequent encounter for closed fracture with routine healing, multiple fractures of pelvis with stable disruption of pelvic ring, subsequent encounter for fracture with routine healing. R32's Minimum Data Set (MDS), dated [DATE], documents a Brief interview of mental status as a 14 which indicates R32 is cognitively intact. R32's MDS also documents R32 as limited assist of one staff member with transfers, bed mobility, walking, dressing, toilet use and hygiene. R32's Progress Note dated 7/22/2022 at 6:03 PM written by V17, Licensed Practical Nurse (LPN) documents This nurse and another staff member heard resident yelling help. Upon entering the room, resident was observed in floor in the bathroom doorway. She way laying on her right side. This nurse asked resident what she was doing at the time of the fall. She stated, She peed on the floor, so I put paper towels over it and was trying to step over them and I lost my balance. Resident c/o (complained of) pain in her right foot and right elbow. She stated, 'I hit my head real hard.' Neuros WNL (within normal limits) ROM (range of motion) X4 with some pain in [NAME] (upper right extremity). 3.75 cm (centimeter) X 2.5cm skin tear to right elbow. Cleansed with soap and water. 6 steri strips applied. Open to air. Resident c/o pain in right elbow. Right elbow has bruising and swelling. Educated resident on asking for help and using her call light when she needs assistance. Resident understood. MD (medical doctor) made aware. POA (Power of Attorney) called but was busy and was not able to leave a message. Will continue to monitor. R32's progress notes dated 7/22/2022 11:21 PM written by V16, Registered Nurse (RN) documents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Resident continues to complain of pain to right elbow. Swelling continues with bruising. Skin tear has been bleeding a small amount at times, dressing applied. Response pending from MD. Elbow elevated on pillow and encouraged not to bend or move it to much at the elbow. Continues on routine Tylenol. Reminded to ask for assistance with all transfers. Will continue to monitor. Residents Affected - Few R32's Progress Note, dated 7/23/2022 6:03 AM written by V16 documents Orders received for x-ray of right elbow to be done this morning. Immobilize elbow and monitor. Orders carried out and Bio tech x-ray notified. R32's Progress Note dated 7/23/2022 at 3:35 PM written by V11, LPN, documents Dressing to rt (right) elbow changed due to bleeding. (Xray company) here this afternoon to obtain x-ray of arm. R32's Mobile X-ray company faxed results to the facility, dated 7/23/22 at 6:09 PM, documented Acute avulsed (small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) fracture proximal ulna (olecranon process). Avulsed fragments vs osteophytes radial head and lateral condyle of humerus. Soft tissue swelling seen around elbow joint. R32's Progress Note, dated 7/23/200 9:12 PM documents Tear to right elbow. Right arm is immobilized and elevated on pillows for comfort. Does complain of pain continues on routine Tylenol. X-ray results still pending. Lung sounds remains diminished in bilateral lower bases. Continues to have a non productive dry cough. Sitting up in recliner for pain relief. She is using the stand aid to help with transfers. Will continue to monitor. This Note did not document R32's physician was notified of the x-ray results. R32's Event Report, dated 7/23/2022, includes documentation of pain assessment of right elbow and foot at an 8 on a scale of 1-10. this also documents location of injury to right elbow including bruising, bump, swelling and Range of motion painful/limited to upper extremity. R32's Progress Note, dated 7/24/22 at 10:10 AM documents (X-ray company) x-ray results received impression: acute avulsed fracture proximal ulna (olecranon process), avulsed fragments vs osteophytes radial head and lateral condyle of humerus and soft tissue swelling seen around elbow joint. On call (Nurse Practitioner) made aware and stated to immobilize arm, and to follow with ortho tomorrow 7/25/22. On 11/16/2022 at 2:30 PM V1, Administrator, states she expects her staff to provide prompt care when residents area experiencing a pain and swelling with limited ROM. V1 stated she expected staff to call the doctor after hours instead of faxing. V1 stated that V17 is no longer employed due to issues such as this occurrence. On 11/17/2022 at 8:40 AM V16 stated that V17 had faxed the doctor instead of calling the doctor about R32's fall. V16 stated she called the on called doctor and he returned the call around 4am and gave orders to have an Xray of R32's elbow to be completed in the morning. V16 stated that she called the portable Xray company to see if they could do the Xray because it was the weekend. R32's Progress Note, dated 7/25/2022 signed by Orthopedic doctor documenting: non-weight bearing (NWB) right upper extremity (RUE), encourage Range of motion (ROM) elbow flexion, and sling for comfort. R32's Physician services Note, dated 7/25/2033 documents that contains chief complaint right elbow (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Actual harm Residents Affected - Few fracture date of injury 7/23/2022. This document also includes documentation stating On July 23, 2022, patient was in the bathroom when she fell backwards and sustaining a direct impact injury onto her right elbow. She immediate pain in her elbow as well as 2 large skin tears. The Note documents Present clinical examination and imaging are consistent with a left olecranon fracture with displacement and intra articular extension. The family understands that the patient would need surgery to reestablish the extensor mechanism of her elbow, without surgery she will not be able to push up from a chair or pressed down on a walker. R32 stated on 11/15/2022 at 11:00 AM that she had fallen in the bathroom and broke her elbow a few months ago on a weekend and went to the orthopedic doctor on Monday. Policy titled Emergency Care policy Procedure documents immediate care of the resident for falls, check for any apparent dislocation or possible fracture. if signs of this are noted, stabilize resident until ambulance arrives. his document also states care of possible Fractures-transport to hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview, the facility failed to administer medications as ordered. There were 28 opportunities with 2 errors resulting in a 7.14% medication error rate. The errors involved one resident (R3) in the sample of 17 residents observed during medication administration. Residents Affected - Few Findings include: 1. On 11/16/2022 at11:25 AM, V14, Licensed Practical Nurse (LPN) was administering medications for R3. V14 removed a plastic neb vial out of drawer on med cart. Surveyor requested box with order on it, V14 stated not one just laying in drawer by his stuff. V14 then entered medication storage room and attempted to access convenience box medication. V14 was unable to access the convenience box. V14 stated I will get it later. V14 then popped clonazepam, 0.5 milligrams (mg), Gabapentin 300 mg, and Hydrocodone 5/325 mg out of medication card and placed in medication cup. V14 handed medication cup to R3. R3 dropped the Gabapentin 300 mg from medication cup into the front of his shorts. V14 removed medication from R3's shorts and wasted medication. V14 did not administer R3 Gabapentin 300 mg. R3's Medication Administration Record (MAR) dated 11/1/2022 through 11/16/22 documents that R3 is prescribed Gabapentin 300 mg three times a day for generalized idiopathic epilepsy. R3's MAR documents on 11/16/2022 11:00am-1:00PM not administered; dropped on the floor. R3's MAR dated 11/16/2022 documents DuoNeb (ipratropium-albuterol solution for nebulization; 0.5miiligram (MG)-3mg (2.5mg base) /3 milliliters (ML)administer1 via inhalation. R3's MAR documents R3 has a diagnosis of chronic obstructive pulmonary disease. On 11/17/22 at 01:19 PM, V1, Administrator stated she would have expected the nurse to provide medication as ordered, and after wasting dropped dose. The facility policy Medication Administration dated revised 02/04 documents #6 all medications must be administered to the resident in the manner and method as prescribed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to label medications including insulin pens and Tubersol vials when opened per standards of practice and failed to ensure only medications are kept in medication refrigerators. This has the potential to affect all 48 residents living in the facility. Finding include: 1. On 11/21/22 at 10:44 AM, the main nursing station medication room was observed with V24 Registered Nurse (RN). The medication refrigerator had 2 bottles of breast milk and a Tubersol (Tuberculin Purified Protein Derivative) vial that was almost empty. The vial failed to have a date on it. On 11/21/22 at 10:44 AM, V24, stated that the breast milk was hers. On 11/21/22 at 11:30 AM, V1, Administrator, stated that breast milk should not be kept in the medication refrigerator. The Tubersol insert, undated, documents, A vial of Tubersol which has been entered and in use for 30 days should be discarded. 2. On 11/14/22 at 11:30 AM, V10, Licensed Practical Nurse (LPN) went to give R37 4 units of Lispro using R37's insulin pen. The pen was opened, and it was not dated as to when it was opened. The prescription was rubbed, and you could not read the dispensed date. In the medication cart, R37 had a vial of Lispro that had been opened it and it did not have a date on it. R37's Face Sheet, undated, documents that R37 was admitted on [DATE] and has a diagnosis of Type 2 Diabetes. R37's November 2022 Physician Orders documents, Insulin Lispro solution; 100 units/milliliter amount; per sliding scale. Before meals and at bedtime. The Lispro injection patient Information Sheet, undated, documents, Throw away on opened vial after 28 days of use, even if there is insulin left in the vial. On 11/17/22 at 2:00 PM, V2, Director of Nursing, (DON), stated that medication vials and insulin pens should be dated when they are opened. The Resident Census and Conditions of Residents, CMS 672, dated 11/14/22, documents that facility has 48 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store food in storage container to prevent contamination, maintain a clean kitchen, label outside food with a name and a date, wash hands upon entering the kitchen and maintain an air gap for an ice machine to prevent the contamination and prevent food borne illness. This has the potential to affect all the 48 residents living in the facility. Findings include: 1.On 11/15/22 at 11:57 AM, V6, Cook, entered the kitchen. V6 went to the steam table and began to serve the noon meal. V6 failed to wash his hands before serving the meal. The Hand Washing Procedure, dated 8/19, documents, When to wash hands: Every time you enter the kitchen or satellite pantry. 2. On 11/15/22 at 11:45 AM the kitchen was observed. There was a metal knife block that holds 7 knives. The top of the block where the knives are inserted was layered in food crumbs. There is a plastic container of dry milk observed with a plastic cup in the dry mix. 3. On 11/15/22 at 12:37 PM, the nourishment room was observed. There is a half drank McDonald's milkshake/ coffee in the refrigerator with no name or date on it. 4. On 11/15/22 at 12:42 PM, the Memory Unit refrigerator was observed. There was a half drank Snapple with no name on it. There was a half drank bottle of water with no name on it. There was a 46-ounce jar of applesauce that was opened that was not labeled with an opened date. There was no thermometer in this refrigerator. In the cabinet on the Memory unit there was a bag of rice krispies and a bag of chips that were not in an air-tight container with packaging just folded down. On 11/15/22 at 12:00 PM, V23, Dietary Manager, stated that there should not be any cups in bulk dry goods, all brought in food for residents should have their name on it and it should be dated, all refrigerators should have a thermometer in them to check the temperature, a bulk dry goods should be in a sealed container, all employees should wash their hands when they enter the kitchen, no employee food should be in the nourishment refrigerators and that the kitchen should be kept clean. The policy Storage of food brought to residents by visitors and volunteer organizations, dated 11/16, documents, 2. Foods that require refrigeration or freezing such as yogurt, ice cream, frozen entrees, restaurant leftovers, etc., brought in from outside will be labeled with the resident's name and the current date. The items will be kept in the refrigerator or freezer of the dining room satellite pantry or nursing nourishment room. Food must be in original package or sealed container. Staff will designate an area for resident's food in the refrigerator or freezer. staff will monitor resident's food and dispose of food that shows signs of spoilage or food that is older than 7 days from the date item was brought to the facility. The Sanitation and Safety Policy, dated 9/10, documents, It is the policy of the facility to provide residents with foods that are safe, wholesome, prepared and served under standard sanitary conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many The policy Purchasing, Receiving and Food Storage, dated 9/10, documents, Food not subject to further washing cooking before being served shall be stored in a way that protects it against contamination. 5. On 11/15/22 at 1:17 PM, the main dining room ice machine was observed. The ice machine drainpipe went directly into a PVC pipe that goes into the drain with no air gap. With no air gap, if the facility had a sewer back up the wastewater would enter the ice machine drainpipe. On 11/16/22 at 2:30 PM, V15, Maintenance Director, stated that he was not aware that the ice machine was that way. The Resident Census and Conditions of Residents, CMS 672, dated 11/14/22, documents that facility has 48 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to conduct Quality Assessment and Assurance meetings at least quarterly and failed to have an infection preventionist on the committee. This failure has the potential to affect all the 48 residents living in this facility. Residents Affected - Many Findings include: On 11/16/22 at 1:00 PM, V1, Administrator, stated the facility has not conducted a quarterly Quality Assurance meeting in the last year. V1 stated I have no sign in sheets of who attended because we did not meet. V1 stated that they do not have an agenda for Quality Assurance meetings because they haven't had a meeting in over a year. On 11/16/2022 at 2:30 PM V2, Director of Nursing, confirmed the facility has not had a Quality Assurance Quarterly meeting. On 11/14/22 at 9:30 AM V1 stated they do not have an infection preventionist. On 11/16/22 at 2:00 PM V2 stated that the facility does not have an infection preventionist. V2 stated the facility is trying to hire one but currently do not have one. Facility policy titled Quality Assurance Performance Improvement, revised 6/1/22, documents A QAA (Quality Assessment and Assurance) committee shall be developed and meet on a quarterly basis and the facility will track medical errors and adverse resident events, analyze their causes and implement preventative actions needed. The Policy documents 2. A QAA committee shall meet on a quarterly basis. Members shall include but are not limited to those listed above. The Policy documents the Infection Preventionist is staff who is involved in QAA. The Resident Census and Condition s of residents, CMS 672, dated 11/14/2022 documents that the facility has 48 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm A. Based on observation, interview and record review, the facility failed to disinfect a multi-use blood glucose machine in between residents' and perform hand hygiene and glove changes to prevent the spread of potential infection for 7 of 10 residents (R3, R4, R20, R21, R30, R36) reviewed for infection control in the sample of 33. Residents Affected - Few B. Based on interview and record review, the facility failed to implement a water policy and procedure to prevent water borne illness including Legionella Disease. This has the potential to affect all 48 residents living in the facility. A. Findings include: 1. On 10/14/22 at 10:43 AM, V10, Licensed Practical Nurse (LPN) entered R20's room and obtained a blood glucose level of 252. When finished she returned to the medication cart and obtained a Micro-Kill Germicidal Alcohol cleansing wipe and placed it down on the cart, V10 then placed the blood glucose machine on top of the wipe and then placed a new cloth over it. V10 failed to cleanse the machine. V10 removed her gloves and failed to sanitize her hands. At 10:45 AM, V10 obtained a blood glucose machine that was on the medication covered with a Micro-Kill cloth. V10 went to R36's room and obtained a blood sugar of 143. V10 exited the room and placed a Micro-Kill cloth on her medication cart, placed the blood glucose machine on top of the cloth, and then placed a Micro-Kill wipe over the machine. V10 did not cleanse the machine. At 10:46 AM, V10 took the blood glucose machine that she had used on R20, and she entered R21's room and obtained a blood glucose level on R21 of 303. V10 returned to her medication cart, obtained a Micro-Kill wipe placed it on the medication cart, placed the blood glucose machine on the cloth then placed another on top of the machine. On 10/14/22 at 3:00 PM, V2, Director of Nurse, stated that The blood glucose machine should be scrubbed for one minute to be clean. The facility provided undated list documents R20, R21, and R36 are the residents that receive blood glucose checks on the 100-hall. The Medline Micro-Kill One Germicidal Alcohol wipes label, documents, Cleaning procedure: Blood and other body fluids must be thoroughly cleaned from surfaces and objects before application of Medline Micro-Kill One Germicidal Alcohol wipes. Contact time: Allow surface to remain wet for 1 full minute. 2. On 11/16/2022 at 11:30AM, V14, Licensed Practical Nurse (LPN) did not sanitize hands prior to medication administration. V14 popped Gabapentin out of the medication card into her hand and then put in the medication cup and handed to R3. On 11/16/2022 at 11:45 AM during medication administration V14 did not sanitize hands prior to donning gloves. V14 then administered one drop (gtt) to R30's right eye. V14 then removed gloves and sanitized hands with hand sanitizer. 3. On 11/15/2022 at 1:30 PM, during incontinent care V22, Certified Nursing Assistant (CNA) donned gloves and did not sanitize hands prior to donning gloves. V5, CNA placed gait belt around R4's waist V5 donned gloves and did not sanitize hands prior to donning gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The facility policy Perineal Care dated revised 6/17 documents #3 wash hands and put on disposable gloves. #7 remove gloves and wash your hands Finding include: B. On 11/16/22 at 1:27 PM, when questioned regarding a water management program to minimize the risk of Legionella, V15, Maintenance Director, stated, I don't do anything specific related to Legionella disease. He further stated that he does not do any type of water tests / water management plan. On 11/16/22 at 1:45 PM, V15, stated, I just found a policy on Legionnaires' disease and Water Management. V15 further stated, I just took over this job 2 months ago. V15 was questioned if the facility had put the procedures outlined in the facility policy into place and V15 stated, I do not think so. On 11/17/22 at 12:20 PM, V1, Administrator, stated, I have a water company that has come in and handles the water for Legionella disease. (V15) did not know I had this, here is the paperwork. The paperwork was reviewed. The paperwork was an outline of a plan that V15 needed to put into place. On 11/17/22 at 1:30 PM, V1, was questioned if V15 had put the plan the water company had outlined into place, V1 stated that she does not believe so. The policy Legionnaires' Disease and Water, dated 8/21, documents, It is the policy of the facility to reduce the risk of growth and spread of Legionella Infections and other opportunistic pathogens in the facility water systems. Prevention: The key to preventing Legionnaires' disease is maintenance of the water systems in which Legionella may grow. It continues, CDC (Center for Disease Control) encourages all building owners, and especially those in healthcare facilities, to develop comprehensive water management programs to reduce the risk of Legionella growth and spread. The Resident Census and Conditions of Residents, CMS 672, dated 11/14/22, documents that facility has 48 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145837 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Level of Harm - Minimal harm or potential for actual harm Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on interview and record review, the facility failed to employ a Certified Infection Preventionist. This failure has the ability to affect all 48 residents living in the facility. Residents Affected - Many Findings include: On 11/14/22 at 9:30 AM V1, Administrator stated the facility does not have an infection preventionist. On 11/17/22 at 1:43 PM, V2, Director of Nursing, DON, stated that the facility does not have an Infection Preventionist. V2 stated We are trying to fill the position. The policy Infection Control, dated 12/17/19, documents, Infection Control Committee Members. 1. Administrator 2. Director of Nurses 3. Infection Preventionist - designated coordinator of the Infection Prevention Control Program. The Resident Census and Conditions of Residents, CMS 672, dated 11/14/22, documents that facility has 48 residents living in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145837 If continuation sheet Page 12 of 12

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Citations

20 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
0029GeneralS&S Fpotential for harm
Develop a communication plan.
0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
0133GeneralS&S Epotential for harm
Install a two-hour-resistant firewall separation.
0321GeneralS&S Dpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0918GeneralS&S Fpotential for harm
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
0923GeneralS&S Epotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
0684SeriousS&S Gactual harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Fpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0868GeneralS&S Fpotential for harm
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0882GeneralS&S Fpotential for harm
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

FAQ · About this visit

Common questions about this visit

What happened during the November 22, 2022 survey of PITTSFIELD MANOR?

This was a inspection survey of PITTSFIELD MANOR on November 22, 2022. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at PITTSFIELD MANOR on November 22, 2022?

Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and maintain an Emergency Preparedness Program (EP)."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·November 22, 2022