Inspection·May 22, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain physician ordered laboratory testing in 1 of 3 residents (R2), reviewed for medication monitoring in the sample of 9. This failure resulted in R2 being admitted to the hospital on [DATE], where he remains. R2 was diagnosed in the hospital with Supratherapeutic INR (Initial Normalized Ratio) with a level greater than 10 (target range is between 2-3) and had to receive medication to reverse the effects from the anticoagulant, Warfarin, that R2 was receiving in the facility for a diagnosis of Pulmonary Embolism. This failure resulted in an immediate jeopardy when the facility failed to obtain laboratory testing to monitor R2's anticoagulant levels to ensure a therapeutic level was obtained. Residents Affected - Few The Immediate Jeopardy began on 4/23/24, when the facility failed to obtain a PT(Prothromin Time)/INR to ensure a therapeutic level was obtained due to the use of an anticoagulant. On 5/21/25 at 9:35 AM, V1, Administrator, V7, Regional Director of Operations, and V8, Chief Operating Officer, were notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review, the Immediate Jeopardy was removed on 5/22/25, but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: On 5/20/25 at 10:30 AM, V5, R2's Sister, stated R2 is currently in the hospital preparing for surgery to remove a large cancerous mass in his intestines. V5 stated she is concerned about R2's Coumadin not being checked at the facility like it is supposed to be, it is to be checked weekly and hasn't been checked since March 2025. V5 stated when R2 was in the ER (Emergency Room) his blood count was 3 and his INR which is supposed to be between 1-2 was greater than 10. V5 stated this is not acceptable and whoever is to be checking to make sure his INR is being checked failed, the bedside care and the nurses are good at the facility and have saved R2's life a few times, but this is unacceptable. R2's ER (Emergency Room) Notes, dated 5/8/25, document R2's INR was greater than 10, R2 was started on Vitamin K and Kcentra (medication used to reverse the effects of Warfarin). Admit to ICU (Intensive Care Unit) for multiple problems, critically ill patient. Impression: Sepsis, Leukocytosis, GI (Gastrointestinal) Bleed, Elevated Lactic Acid Level, Elevated INR. R2's History and Physical, dated 5/8/25, documents the following: Impression - Acute Blood Loss Anemia, Probable GI Bleed, Supratherapeutic INR, Hx of PE. Reversal of Coumadin with Kcentra. R2's Hospital Laboratory Results, dated 5/8/25, document R2's Hgb (Hemoglobin) level was 3.8 (normal range is 14 - 18); PT (Prothrombin Time) level of greater than 80 seconds (normal range is (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: 145783 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 145783 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sunrise Skilled Nur & Rehab 333 South Wrightsman Street Virden, IL 62690 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)