Health inspection·September 26, 2024

F 0760 Ensure that residents are free from significant medication errors. 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 follow physician orders for a resident's anticoagulant medication (Warfarin/Coumadin) resulting in the resident receiving an increased anticoagulant dosage for 24 days. The facility also failed to monitor the resident's anticoagulant medication as recommended by the drug manufacturer guidelines. These failures affect one (R1) resident reviewed for anticoagulation therapy on a sample list of three residents. These failures resulted in R1 experiencing internal bleeding and dying. Residents Affected - Few Findings include: The Immediate Jeopardy began on [DATE] when the facility failed to follow the physician orders to decrease R1's Warfarin dosage from 3mg to 2.5mg and failed to obtain a PT/INR (Prothrombin Time/International Normalized Ratio (measures blood clotting time)). Twenty four days later, R1's PT/INR were at critical levels, R1 was bleeding internally and was sent to the hospital for Warfarin toxicity where he subsequently died. V1 Administrator was notified of the immediate jeopardy on [DATE] at 3:37PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE] but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The undated Warfarin package insert documents, The dosage and administration of warfarin sodium tables must be individualize for each patient according to the patient's (International Normalized Ratio) INR response to the drug. Adjust the dose based on the patient INR and the condition being treated. Monitoring: Obtain daily INR determinations upon initiation until stable in the therapeutic range. Obtain subsequent INR determination every 1-4 weeks. The National Institute of Health (NIH) report on Warfarin (Coumadin) anticoagulant dated [DATE] documents, Close monitoring of a patient's INR is a strong recommendation when initiating Warfarin. The INR requires more frequent monitoring when starting Warfarin. More frequent monitoring is necessary for patients with supratherapeutic or subtherapeutic INR to evaluate safety and efficacy. Also, the INR requires assessment when initiating, discontinuing, or changing doses of medications known to interact with Warfarin. Patients also require close monitoring for signs and symptoms of active bleeding throughout their treatment. Close monitoring for signs and symptoms of bleeding, such as dark tarry stools, nosebleeds, and hematomas, is necessary. R1's census report dated [DATE] documents admission to the facility. (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 7 Event ID: 145911 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 145911 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Gibson City 620 East First Street Gibson City, IL 60936 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)