Health inspection·February 14, 2025

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, interview and record review the facility failed to administer medications according to physicians orders and manufacturer recommendations for five of 15 residents (R1, R2, R3, R4 and R14) reviewed for medication administration on the sample of 15. The facility had five medication errors out of 37 opportunities resulting in a medication error rate of 13.51 percent. Residents Affected - Some Findings include: 1.) R1's February 2025 Physician Order Sheet (POS) documents an order for Flonase Allergy Relief Nasal Suspension 50 MCG (microgram) 2 puffs each nostril one time a day. On 2/14/25 at 5:33 am V10, LPN (License Practical Nurse) administered R1's medication. V10 did not administer R1's Flonase. On 2/14/25 at 9:43 am V11, LPN stated R1 has an order for Flonase but the medication was not available in the medication cart to give. V1, Administrator stated on 2/14/25 at 11:30 AM This is a stock drug the nurse should have gotten the medication out of the stock medications. 2.) R2's February 2025 POS documents an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 mg (milligram) 1 tablet every 8 hours for pain. On 2/14/25 at 5:43 am V10 did not administer R2's Hydrocodone-Acetaminophen Oral Tablet because there was none available to give. V10, LPN stated, The pharmacy has not arrived to deliver medications so I will not to be able to give it to R2 at this time. At 6:30 am R2 stated This has happened to me before, I receive the medication late because they don't have it available. On 2/14/25 at 11:30 am V1, Administrator stated I will put these items on my list to in-service the nurses about to ensure enough medications are available for the residents especially pain medications. 3.) R3's February 2025 POS documents an order for Trolley Lepta Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT 1 puff every day in AM. Rinse mouth with water and spit back into cup after use. On 2/14/25 at 5:59 am V10 gave R3 the medication and did not instruct R3 to rinse R3's mouth with water and spit back into the cup after using. On 2/14/25 at 9:50 AM V11 confirmed the order stated for R3 to rinse mouth after using the medication. 4.) R14's February 2025 POS documents R14 is to receive Tylenol Oral Tablet 325 mg 1 tablet three times a day. May use stock mediation. On 2/14/25 at 6:04 am V10 gave R14 Tylenol 500 mg 1 tablet from stock medication. On 2/14/25 at 9:50 am V11, confirmed the order states to give Tylenol 325 mg three times a day. (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 2 Event ID: 145422 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 145422 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fair Havens Senior Living 1790 South Fairview Avenue Decatur, IL 62521 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)