VILLAS OF SHANNON                                           
I.D. NUMBER 0043851
418 SOUTHRIDGE 
SHANNON, ILLINOIS 61078  

As a result of a survey conducted by representative(s) of the Department, it has been determined the following violations
occurred.

                               "A" VIOLATION(S)


The facility shall have written policies and procedures governing all services provided by the facility.  The facility shall
assure that resident's plans of care are individualized, written in terms of  short and long range goals, understandable and utilized;
and their needs are met through appropriate staff  interventions.  Adequate, and properly supervised nursing care and personal
care shall be provided to each resident to meet the total nursing and personal care needs of the resident.  Each resident
shall have an up-to-date care plan based on the resident's individual needs and goals to be accomplished, physician's
orders, and personal care and nursing needs.  The plan shall be reviewed and modified in keeping with the care needed
as indicated by the resident's condition.  The facility shall not neglect a resident.  

These requirements are not met as evidenced by:

Based on observation, interview and record review, the facility failed to:  
    
       a)     prevent R-1 from exiting the facility when unsupervised or wearing appropriate clothing for weather conditions,
       b)     assess R-1's behavior of elopement, 
       c)     develop a temporary care plan for R-1 related to elopement or revise R-2 and R-3's care plans related to elopement, 
       d)     monitor R-1 closely to ensure her safety, 
       e)     respond to triggered door alarms, and 
       f)     have an effective safeguard system to prevent elopement that could potentially harm residents who wander for the
       following three of three residents in the sample. 

R-1 has diagnoses that include Alzheimers, Confusion, Parkinson's Disease, and Wandering. R-1 was admitted to the facility on
12/31/98 due to an incident which occurred on 12/30/98. Review of the history and physical from the hospital dated 12/30/98
revealed, "(R-1) left her house and came to the neighbor's house thinking there was a party ... approximately two o'clock in the
morning and she had no coat, no shoes, no hat, no gloves and it was quite cold ..., apparently was found out over the Thanksgiving
holiday as well..., She does not know that it is winter." 

Review of a facility incident report dated 1/7/99 at 11:45am revealed, "A concerned citizen saw (R-1) walking around the street
with housedress and light sweater. (R-1) eloped from the facility ..., Steps to be taken by facility: Elopement procedure begun
with Elopement chart started. Staff to check (R-1) frequently." 

Interview with Z-3 on 1/19/99 revealed, "Estimated temperatures for Shannon, Illinois on 1/7/99 were 4 degrees Fahrenheit for
the high and -18 Fahrenheit for the low. The estimated temperature at 11:45a.m. on 1/7/99 was -5 to -10 degrees Fahrenheit with
a wind chill factor of -15 to -25 degrees Fahrenheit.

Review of the `Elopement Monitoring Sheet' revealed that dates 1/7/99 and 1/8/99 lacked any documentation of monitoring and
dates 1/9/99, 1/10/99, 1/11/99, 1/12/99 and 1/13/99 lacked documentation during one of the shifts on each day. This monitoring
system only showed zeros if no attempts were made. It failed to identify methods of interventions / monitoring or frequency of
monitoring for three of three residents who wander. 

When questioned about facility's expected frequency of monitoring, E-1 commented it should be at least every 15 minutes. 

Review of the facility's incident report dated 1/12/99 revealed, "(R-1) was noted missing at 5:45 a.m. Phone call from the Sister's
Diner at 5:50 a.m., concerned citizen picked (R-1) up walking down  Ridge Street. (R-1) had no shoes on..., extremities cold to
touch, pedal pulses present but faint..."  Review of R-1's admission nurse's notes dated 12/31/98 revealed, "Watch closely for
elopement as she tends to wander...will monitor." 
                              
When questioned if R-1 was assessed and care planned for elopement, E-7 stated, "I did not care plan (temporary) after the 1/7/99
elopement. There was no assessment regarding her wandering or elopement  after the 1/7/99 incident." E-7 presented a care plan
addressing this issue on 1/14/99. On 1/14/99, the facility's alarm system was checked. The alarms on the East and West South
doors were checked. They sounded (buzzed) and turned off in five seconds. E-2 was asked for assistance to check these alarms.
Staff failed to respond to the triggered alarms. The East side reception door was triggered at approximately 10:30a.m.. The alarm
sounded but staff failed to respond. E-1 commented that she worked the night of 1/13/99 and tested this door alarm. She told staff 
to keep the hallway connecting doors to the reception room opened during the day because the alarm could not be heard with the
doors closed.  These doors were observed to be closed during the survey. 

During interview with E-2 on 1/14/99, she commented that she worked on 1/11/99 on the 2-10 p.m. shift and R-1 was observed
standing by the door and looking out. 

An attempt was made to interview R-1 on 1/14/99 relating to the 1/12/99 incident, but the resident was confused to time, place
and person. 

Observation of R-1 on 1/14/99, revealed both feet/toes with edema, redness and very large blisters on the bottom. Measurement
of the blisters were as follows. Left foot had blister across foot just under toes that was 24mm width X 21mm length. The lateral
aspect of foot (bottom) was 27mm X 35mm X 26mm. The blister was fluid filled with an elevation of 11mm. Right foot had a
blister between great and second toe that was 20mm X 22mm. Blister on the bottom was 27mm X 40mm X 23mm, a total of
161mm. This blister was fluid filled with an elevation of 12mm.  Per interview with staff from the weather bureau, it was revealed
that the temperature in Shannon on 1/12/99 at 5:30 a.m. was 9 degrees with a wind chill factor of -19 degrees. 

During interview with Z-2 on 1/14/99 he stated, "I found (R-1) at the end of Ridge Street at the stop sign. (This was observed
to be approximately 4 blocks from the facility. The sidewalks on both sides of the street and Ridge Street were still covered with
snow and ice on 1/14/99). I picked (R-1) up and brought her to the Sister's Diner. (R-1) was only wearing a gown; no shoes, coat,
hat or gloves." 

During interview with E-2 on 1/14/99 she stated, " ...I checked (R-1) at approximately 5:25a.m. (1/12/99). I was in her room about
5 minutes... I left her room and went into other rooms...I did not hear anything (alarm) or see anything." 

2)  R-2 has diagnoses that include Alcoholism and Cerebral Bleed. Review of the physician's order sheet dated 1/3/99 revealed,
"Wander-alert. Level 2." The `Monitoring Sheet' indicated a Level 2 as a `Potential for elopement - requires monitoring'. The
Minimum Data Set (MDS) dated 6/14/98 and 12/18/98 did not identify wandering as a problem behavior and the current care
plan failed to address wandering or elopement.
 
3)  R-3 has diagnoses that include Behavior Problem and Mental Retardation with Bi-Polar Disease. Review of the physician's
order sheet dated 1/3/99 revealed, "Wander alert- Level 2." This is `Potential 300.610a) for elopement - requires monitoring. The
MDS dated 6/11/98 did not identify wandering or elopement. The current care plan failed to address wandering or potential for
elopement.  R-1, R-2 and R-3 were all identified as wanderers on the facility's Elopement Monitoring Sheet