Health inspection·May 7, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow safe medication administration practice to avoid a significant medication error. This applies to 1 of 3 residents (R1) reviewed for significant medication error in a sample of 3. Residents Affected - Few The findings include: On May 6, 2025 at 12:03 PM, R1 said a few weeks earlier, he was given three white pills which he was not supposed to take and were supposed to be for another resident. R1 said he went to the hospital to be evaluated for the reaction to the pills. On May 6, 2025 at 1:33 PM, V3 (RN/Registered Nurse) said she had floated onto a different unit than her normal and had received a phone call from the cardiologist. V3 said she had worked with R1 before but had misheard the cardiologist and did not realize there was another resident who had the same first name and same letter for the last name. V3 said she pulled the medication and went to R1's room and said the labs showed he needed his potassium replaced. V3 administered the potassium to R1 and after taking the medication, R1 said he had not had his labs drawn. V3 said she realized she had administered the medication to the wrong patient and called the cardiologist back. V3 said R1 was sent out to the hospital, where his potassium level showed a normal level of 4.1. On May 6, 2025 at 1:57 PM, V6 (LPN) said when she received an order from the doctor, she would verify the resident's name as well as their date of birth . V6 said when the doctor gives an order, she would read back the orders to the doctor to make sure it was the correct resident. V6 said if a resident had too much potassium, the resident could have cardiac arrhythmias. V6 said if she had administered potassium to a resident who was not supposed to, she would call the doctor, do vital signs, keep monitoring the residents' blood pressure, call 911, notify the family and director of nursing, and fill out an incident report. V6 said she was told R1 was given the wrong medication and was sent to the hospital. On May 6, 2025 at 2:03 PM, V7 (RN) said when she received orders from the doctor, she would say the residents' first and last name. V7 said she would also repeat the orders back to the doctor to ensure she had the correct information. V7 said receiving potassium could cause heart arrhythmias. V7 said R1 had labs collected after returning from the hospital. V7 said R1 did not require kayexalate and he was monitored for a few days after returning, and the highest his potassium levels went were 5. V7 said if she had administered too much potassium, she would call the doctor right away, who would either say to monitor in the facility or send the resident to the hospital. V7 said she would have to fill out a medication error report and call the family. (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 3 Event ID: 146093 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 146093 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Manor - Lagrange 339 9th Avenue LA Grange, IL 60525 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)