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 ensure residents are free from significant
medication errors, by failing to correctly identify a resident prior to medication administration. This failure
affects one resident (R1) out of seven reviewed for medication administration.
Residents Affected - Few
Findings include:
R1's Face Sheet (undated) electronic Census Detail documents R1 was admitted to the facility for this
residency on 9/28/23. R1's (undated) electronic Diagnoses List documents R1 experienced medical
conditions including Congestive Heart Failure, Atrial Fibrillation, History of Myocardial Infarction, Chronic
Obstructive Pulmonary Disease, Type 2 Diabetes, Anxiety, Hypertension, Coronary Artery Disease, and
major Depression.
R1's emergency room After Discharge Instructions dated 8/8/24 documents R1 was treated at the
emergency room for an accidental medication overdose, requiring intravenous fluids, administration of
intravenous Vitamin K 5 milligrams (mg) to reverse the effects of Coumadin (anticoagulant, blood thinner),
1,000 milliliters of normal saline, and oral administration of Vitamin B-12 5 mg.
On 8/15/24 at 10:30 AM, V2, Director of Nursing, stated, I was training a new nurse (V3, Licensed Practical
Nurse), it was her second day working here. R1 had a room change the night before and his nameplate had
not been moved to his new room where he became a roommate of (R2). V2 continued, (V3) got to the room
of (R2) and prepared (R2's) medications. R2's name was the only one on the door but it was (R1) who was
actually in the room at the time. V2 further stated, (V3) gave (R2's) medications to (R1), this was the HS
(bedtime) medications and was around 2100 (9:00 PM). I did counsel (V3) that we don't just go by the
name on the door, we have to look at the pictures in the charts, and that most of our residents can identify
themselves by name. V2 continued, We did end up sending (R1) to the emergency room and they did give
(R1) some Vitamin K, saline, and B-12. V2 concluded by stating, (R1) came back here in just a few hours.
R1's (undated) Electronic Medical Record picture portrayed a standing, tall, thin, caucasian man with clean
shaven face. R2's (undated) Electronic Medical Record picture portrayed a much shorter, rotund, african
american man with a gray beard seated in a wheelchair.
R2's (undated) current electronic Physician Order Sheet documented R2 receives HS medications
including Coumadin 5.5 mg in a combination of a 3 mg tablet and a 2.5 mg tablet (anticoagulant),
Trazadone 100 mg (antidepressant sedative), Lyrica (gabalin analogue, calms overactive nerves, nerve
pain, muscle pain, seizures), Oxcarbazepine 300 mg (anticonvulsant, antiseizure), and Atorvastatin 20 mg
(lowers cholesterol). These medications were confirmed with V2 as having been included in the
medications incorrectly administered to R1.
(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:
146050
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
146050
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Haven of Arcola
422 East Fourth Street
Arcola, IL 61910
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 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R1's (undated) electronic current Physician Order Sheet (POS) documented R1 did not have physician
orders for any of the medications administered to R1 on 8/8/24. This same POS documents R1 does have
physician orders for Apixaban (anticoagulant) 5 mg twice daily at 8:00 AM and 4:00 PM making a
duplicitous medication therapy when given with R2's Coumadin at 9:00 PM. This same POS documents R1
does have physician orders to receive Sertraline 50 mg daily (antidepressant) also duplicitous when
administered with R2's Trazadone. This POS documents R1 has physician orders to receive Buspirone
(antianxiety) 5 mg twice daily at 8:00 AM and 4:00 PM having additive effects when administered with R2's
Trazadone, Lyrica, and Oxcarbazepine.
The facility Medication Administration Policy dated revised 11/18/17 documents, Medications must be
identified by using the seven (7) rights of administration: Right resident, Right drug, Right dose, Right
consistency, Right time, Right route, Right documentation. This same policy documents, Identify each
resident prior to medication administration. Two methods of verification must be utilized prior to
administration of a medication: Check photograph, Ask resident his/her full name, Verify resident's identity
with another employee familiar with the resident, Call the resident by name and ask for confirmation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146050
If continuation sheet
Page 2 of 2
