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.
Based on interview and record review the facility failed to transcribe a physician order to the resident's
Physician Order Sheet to ensure medications are administered as ordered for 1 of 1 resident (R2) reviewed
for pharmaceutical services in the sample of 4.
Findings include:
R2's admission Nursing Assessment, dated 5/2/23, documented diagnoses of Atrial flutter, Prolonged heart
QT waves, Dementia, and Hypertension.
R2's Physician's Order, dated 5/2/23, documents Eliquis 5 milligrams tablet twice a day and scheduled for
8:00AM and 5:00PM for Atrial Flutter of the heart.
On 6/7/23 at 2:10 PM, V3 Licensed Practical Nurse, LPN, stated that R2 had blood in her adult incontinent
brief. V3 stated she telephoned V4, R2's Physician, on 5/27/23 at 7:15 AM, regarding R2's blood in stool. V3
stated she received a verbal telephone order from V4 to hold R2's Eliquis for the 8:00AM scheduled dose
and order a STAT (immediate) hemoglobin and hematocrit (H&H) blood draw and then to notify V4 when
the lab results came back. V3 stated she held the 8:00 AM Eliquis scheduled dose as ordered, obtained
R2's blood sample and sent off to the laboratory immediately. V3 stated the results of the H&H results came
back to the facility within a few hours. V3 stated she notified V4 by telephone and received an order to
continue R2's Eliquis as scheduled. V3 stated she documented on the Medication Administration Record
(MAR) to hold the one single 8:00AM dose; however, failed to transcribe on R2's Physician's Order Sheet
(POS), to continue/resume R2's Eliquis scheduled dosage twice a day.
R2's Skilled Progress Note, dated 5/27/23 at 7:15AM, written by V3 documented, N.O (New order) received
from V4. Please see POS (Physician Order Sheet). The Note documented Resident had large copious
amount of blood in depends in her stool this morning.
R2's, POS, dated 5/27/23, un-timed and written by V3, documents1.) STAT emergency laboratory draw for
H&H blood draw. 2.) Hold Eliquis until H&H result called to V4. 3.) ok to send to ER (emergency room) for
evaluation and tx. (treatment) if another bleeding episode occur.
R2's, Skilled Progress Note, dated 5/27/23 at 10:15AM, documented V4 was called regarding R2's H&H
results and V4 said to continue Eliquis and watch resident if she has another bleeding episode or continues
not to eat or drink all day as V4 would recommend her to be evaluated by Emergency Department and
follow-up with V6, R2's physician.
(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:
145851
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
145851
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/09/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Eastside Health and Rehabilitation Center
1400 East Washington Street
Pittsfield, IL 62363
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
R2's May 2023 MAR, documented, HOLD, written in the 8:00AM check box for the Eliquis, initialized by V3,
who received the order. The MAR documented that R2 received the 5:00 PM dose. The MAR documented
R2 did not receive Eliquis on 5/28/23.
R2's June 2023 MAR, documented R2 did not receive Eliquis on 6/1 and 6/2/23. The MAR documented
HOLD on 6/2/23.
On 6/7/23 at 2:46 PM, V7, LPN stated, she documented in the MAR on 6/1/23 that R2 did not receive her
8:00AM and 5:00 PM dose of Eliquis, as this was reported to her from a previous nurse reporting off work
that R2's Eliquis is not to be given, and stated she wrote the word hold, on the MAR for the following day,
6/2/23. V7 stated she assumed that since R2 had rectal bleeding not to give the Eliquis (blood thinner) and
failed to follow-up with the physician on clarification of the medication order and did not follow-up to look in
R2's POS of a medication order change.
On 6/7/23 at 3:40PM, V5, Registered Nurse for V6's (R2's Physician), stated that V6 did not order to
discontinue R2's Eliquis.
On 6/8/23 at 12:00PM, V1, Administrator, stated she would expect the nursing staff to document and
process physicians order when received.
The facility's policy and procedure, entitled, Pharmacy Medication Orders and Resident's Charts, dated
10/06, documents, Telephone orders are to be written on the special Physician's Telephone Orders form,
and signed by the nurse taking the order. Whenever possible, the licensed nurse receiving the physician
order should completely transcribe the order before returning the chart to the rack. Transcription includes
transcribing the order to the following: The POS, MAR. All orders must include complete directions,
including frequency, special directions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145851
If continuation sheet
Page 2 of 2
