Inspection·September 12, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents are free from significant medication errors for 1 of 3 residents (R1) reviewed for medication errors in sample of 13. This failure resulted in R1 receiving another resident's medication and being hospitalized for hypoglycemia.Findings Include:R1's Face Sheet shows documents an admission date of 10/16/2023 and includes diagnoses of Type 2 diabetes mellitus without complications, Alzheimer's Disease, Iron Deficiency, Cholecystitis, Renal Insufficiency, and Diaphragmatic Hernia without Obstruction. R1's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, documents a Brief Interview for Mental Status (BIMS) score of 5, indicating R1 has severe cognition impairment. R1's Progress Note dated 8/30/2025 at 8:46AM, documents Asked patient (R1) her name she said it was other residents name gave her that residents meds. BG (blood glucose) was 44 so gave orange juice with sugar to raise BG to 77. Notified ADN (V3 Assistant Director of Nursing), called ambulance, notified provider (name of provider).R1's Progress Note dated 8/30/25 at 10:35PM documents that the local hospital was contacted for an update and R1 was admitted for Hypoglycemia.On 9/5/2025 at 3:16PM, V9 (Licensed Practical Nurse/LPN) stated she was the nurse that accidentally gave R1 the wrong medications. V9 said prior to administering the wrong medications to R1, she saw R1 while R1 was in R1's room lying in bed. V9 stated when she checked R1's blood sugar, R1's blood sugar was 44. V9 said she provided R1 with some orange juice. V9 said after R1 drank the orange juice V9 rechecked R1's blood glucose and it had come up to 77. V9 said later in V9's shift (during morning medication pass) R1 was sitting in the dining room and when V9 asked R1 her name, R1 gave V9 the wrong name and gave the medications of the name (the name of R6) R1 gave her. V9 stated after she gave R1 the medications, a CNA stated, that is R1 not R6. V9 stated that is when she knew she made a medication error. V9 stated she could not remember what the medications were that she administered to R1 but they were R6's morning meds. V9 said when she realized the medication error had occurred, she reported this to V2 (Director of Nursing/DON) and then she sent the resident to the Emergency Room. V9 stated she does not work very often because she is in school, so she is not real familiar with some of the residents. V9 stated she also had called the physician and the Power of Attorney about the incident. V9 stated she had not administered R1's medications that were prescribed for that morning ordered for 7:00 AM to 10:00 AM after realizing her error. V9 stated she just received education from V2 on the date the medication error occurred (8/30/2025), on Medication Administration.R6's Medication Administration Record shows the AM (7:00AM-10:00AM) medications ordered for R6 that was given to R1 were Colace 100mg capsule, Ferrous Sulfate 325mg tablet, Furosemide 20mg tablet, Gabapentin 100mg capsule, Januvia 100mg tablet, Levothyroxine 125 mcg tablet, Lisinopril 20mg tablet, Magnesium Oxide 400mg tablet, Metformin 500mg tablet plus 250 mg tablet to equal 750 mg total, and Vitamin D3 50mcg capsule. R1's Physician Order Sheet documents an order for Lantus Solostar Insulin of 15 units subcutaneous once a day with an order date of 10/16/2023 and an order for BS checks dated 10/16/2023 Residents Affected - Few (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: 146045 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 146045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Energy 210 East College Energy, IL 62933 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)