Health inspection·November 12, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to correctly identify a resident prior to administering medications resulting in a resident receiving another resident's medications. This failure affects one of 12 residents reviewed for medication administration in the sample list of 14. Residents Affected - Few Findings include: The Physician Order Sheet dated October 2024 documents R1's primary diagnoses as Chronic Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure, Acute Respiratory Failure with Hypoxia, and Sepsis and R1's Hospice diagnoses as Chronic Ischemic Heart Disease, Heart Failure, and Unspecified Atrial Fibrillation. R1's BIMS (Brief Interview for Mental Status) for R1's annual assessment in October 2024 documents R1 as severely impaired with decision making skills. R1's MDS (Minimum Data Set) dated October 2024 documents R1 requires a mechanical lift for transfers to his special design wheelchair and R1 requires all activities of daily living to be completed by staff to including feeding. On 10/29/24 at 8:15 AM, the facility report titled MED ERROR was completed by V5 Registered Nurse (RN) documenting Agency nurse (V5) mistakenly gave resident (R1) medication meant for another resident (R2). The report continues to state Immediate Action taken: Vital signs were checked routinely, blood pressure dropped. Called hospice and did not hear back. Called Medical Director (V8) to explain incident and Medical Director (V8) gave order for normal saline given at 100 ml (millimeters)/hour until BP (Blood Pressure) normalized. Daughter/POA (Power of Attorney) notified as well. The report continues to state under other information: Agency Nurse (V5), second day in the facility. Two male residents with the same last name. Incident occurred in the dining room. The Section titled Statements includes a statement from V9 CNA (Certified Nursing Assistant) on 10/30/24 no time given, that documents I was in the dining room assisting with feeding residents and the Agency RN (V5) was noted to be giving (R1) thin liquids when (R1) is to receive thickened liquids. I said something to (V5) who continued to give thin liquids with medication and then (V5) stated he thought he was the other resident (R2). The Physician Order Sheet dated October 2024 documents R2's morning medications (which were administered to R1 on 10/29/24) as Amiodarone HCL 200 mg (milligram) (Antiarrhythmic), Clopidogrel Bisulfate 75 mg (Anticoagulant), Ferrous sulfate 324mg (Iron Supplement), Hydralazine HCL 50 mg (Antihypertensive), Isosorbide Mononitrate ER 60 mg (Diuretic), Lorazepam 1 mg (Antianxiety), Pantoprazole Sodium 40 mg (Anti-reflux), Potassium Chloride ER 20 meq (milliequivalent)(Supplement), Terazosin HCL 5 mg (Antihypertensive), Valsartan 160 mg (Antihypertensive), Vancomycin 125 mg (Antibiotic) and Vitamin B12 1000 mcg (microgram). (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: 145636 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 145636 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Charleston Rehab and Nursing 716 Eighteenth Street Charleston, IL 61920 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)