Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure medications were administered as
ordered for 1 (R5) of 3 residents reviewed for medication administration in the sample of 5.Findings
Include:R5's face sheet documents that R5 was admitted to the facility on [DATE]. The diagnoses listed on
the face sheet include unspecified fracture of left pubis, urinary tract infection, heart failure, unspecified
atrial fibrillation, essential hypertension, chronic kidney disease, and hyperkalemia. R5's admission MDS
(Minimum Data Set) dated 10/13/2025 documented a BIMS (Brief Interview of Mental Status) of 15,
indicating R5 is cognitively intact.R5's progress note dated 11/11/2025, timed 12:25 A.M., authored by V12
(Licensed Practical Nurse) documented R5 received Keppra 750mg and Metoprolol 100 mg in error. The
on-call nurse practitioner called and notified him of error. Vital signs at 10:39 P.M. were blood pressure
128/52 and pulse of 74. Per nurse practitioner monitor vital signs during the evening. 11:03 P.M. blood
pressure 118/56 and pulse 69. On call facility nurse notified of error. R5 currently at nurses' station for
monitoring. No adverse reactions noted. Power of Attorney notified. R5's progress note dated 11/23/2025,
timed 11:48 A.M., authored by V19 (Licensed Practical Nurse) documented R5 has no adverse side effects
from medication error on last shift. R5 able to voice needs. No new orders at this time.R5's Order history
with a date range of 10/07/2025-02/10/2026 document no orders for Keppra or Metoprolol. On 02/06/2026
at 9:23 A.M. V2 (Director of Nursing) stated the facility has not had any medication errors and does not
have any medication error reports.On 02/06/2026 at 2:02 P.M. V6 (Licensed Practical Nurse) stated there is
a nurse on night shift that gave the wrong resident the wrong medications. V6 stated this has been reported
to V2 and nothing was done about it. V6 stated the nurse who made the medication error still talks about it
occurring. On 02/06/2026 at 2:20 P.M. V8 (Licensed Practical Nurse / Assistant Director of Nursing) stated
she is not aware of any medication errors.On 02/08/26 at 4:52 AM V12 (Licensed Practical Nurse) stated
there was an incident about two months ago when she was helping another nurse with her mediation pass.
V12 stated she was passing the C hallway and the right side of A hallway, and the other nurse was passing
B hallway and the left side of A hallway. V12 stated the other nurse was running a little bit behind so she
decided to help them out. V12 stated she probably shouldn't have done it but she did. V12 stated she went
down and pulled the residents medication out of the med-cart and took it down to the A hallway. V12 stated
she had the medication pulled for the resident in the second room on the left and she accidentally gave
them to the person in the first room on the left side of the A hallway. V12 stated she reported it immediately
to the DON, family, and the doctor. V12 stated she monitored R5's vital signs and they kept R5 up close to
the nurse's station so they could monitor them closely. V12 stated she charted and done everything she
was supposed to regarding the incident.On 02/10/2025 at 10:58 A.M. V2 (Director of Nursing) stated she
asked V12 (Licensed Practical Nurse) when she was in the facility over the weekend about what the
surveyor had asked her
(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:
145601
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
145601
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Aviston Countryside Manor
450 West 1st Street
Aviston, IL 62216
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
about. V2 stated V12 told her about medication error questions. V2 stated she asked V12 how she
responded and V12 told her that she told the surveyor about when she gave the wrong medications to the
wrong resident. V2 stated she was not aware at the time of the incident and was only made aware the other
night. V2 stated she is aware that it was a resident on A hall, and the resident had been discharged . V2
stated she is actively reading through charts trying to determine who the resident was.On 02/10/2026 at
11:34 A.M. V2 stated that she has determined that R5 was the resident who was given the wrong
medication. V2 stated she looked and V8 (Licensed Practical Nurse / Assistant Director of Nursing) would
have been the nursing administration on call. V2 stated she asked V8 and V8 stated she was not made
aware of the medication error. V2 stated if she had been notified herself and V8 would have investigated it
and followed the facility policy on medication errors.On 02/20/2025 at 12:54 P.M. V1 stated he was not
made aware of the medication error until today. V1 stated that it is his expectation for all medication errors
to be reported and handled appropriately. V1 stated he expects the facility follow all proper nursing
standards to prevent medication errors.Facility policy titled Preventing and Detecting Adverse
Consequences and Medications Errors documents J. The following information is documented in an
incident report and in the resident's clinical record: 8) factual description of error, 9) name of physician and
time notified, 10) physician's subsequent orders, 11) resident's condition for 24 -72 hours or as directed. K.
Each incident report is forwarded to the Director of Nursing / Quality Assurance, Medical Director /
Consultant Pharmacist.
Event ID:
Facility ID:
145601
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation 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.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
FAQ · About this visit
Common questions about this visit
What happened during the February 11, 2026 survey of AVISTON COUNTRYSIDE MANOR?
This was a inspection survey of AVISTON COUNTRYSIDE MANOR on February 11, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVISTON COUNTRYSIDE MANOR on February 11, 2026?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.