Health inspection·June 20, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to notify the Physician of medications that were not administered in 2 of 6 residents (R2, R6) reviewed for Physician notification in the sample of 6. Findings include: 1. On 6/16/23 at 1:25 PM, R6 stated, sometimes they give her medicine to her at night and sometimes they don't. Stated, she doesn't remember the exact dates, but she told the staff in resident council that she wasn't getting her medications at night. The resident Council Minutes, undated, document R6 had her pills put on her table while she was asleep, they spilled during the night, and she did not get her medications. R6's Face Sheet, undated, documents, R6 has a diagnosis of End Stage Renal Disease, Type 2 Diabetes, Hypertension, Anxiety, Anemia, Pain, Major Depressive Disorder and Chronic Respiratory Failure. R6's Minimum Data Set, (MDS), dated [DATE], document R6 is cognitively intact. R6's Care Plan, dated 8/16/19, documents, the following: R6 has Diabetes and to administer insulin as order; R6 has anxiety, depression, insomnia and to administer buspirone 15 milligrams (mg) 3 times daily as ordered. R6's Physician Order Sheets, (POS), documents the following orders: 6/11/21 - Aspirin 81mg daily; 3/31/23 - Buspirone 15mg 3 times daily; 6/11/21 - Lantus 12 units twice daily; 4/29/22 - Montelukast 10mg daily; 3/30/23 - Pantoprazole 40mg daily and 10/26/22 - Renvela 800mg 3 times daily. R6's Medication Administration Record, (MAR), documents, the following: 4/20/23 - Buspirone and Montelukast was not given 10 times and the Pantoprazole was not given 6 times in the month of April; 5/2023 - Aspirin, Lantus and Pantoprazole was not given 7 times, the Buspirone was not given 6 times and the Renvela was not given 14 times in the month of May; 6/2023 - Aspirin, Lantus and Pantoprazole was not given 7 times, Buspirone was not given 2 times and Renvela was not given 9 times in the month of June. R6's Progress Notes were reviewed and there is no documentation, that R6's physician was notified of the medications that were not administered. 2. R2's Face Sheet, undated, documents a diagnosis of Dementia, Hemiparesis/Hemiplegia following a (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 4 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 06/20/2023 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)