Health inspection·August 27, 2024

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 administer a Physician prescribed medication as ordered. This applies to one of three residents (R1) reviewed for medication administration in the sample of six. Residents Affected - Few The findings include: The facility face sheet shows R1 was admitted to the facility with diagnoses to include Type 2 Diabetes Mellitus, congestive heart failure and hypertension. The facility assessment dated [DATE] shows R1 to be cognitively intact and requires moderate assistance with his activities of daily living. On 8/27/24 at 9:30 AM, V2 (Director of Nursing) said she was the nurse working the floor on 8/18/24. V2 said she was having a very busy night with another resident having a change in condition. V2 said she was running behind in her bedtime medication pass and was also trying to give a shift to shift report to the oncoming nurse. V2 said she looked at the Medication Administration Record (MAR) and saw the order for R1's scheduled insulin and she prepared that and then drew up 40 units of R1's regular sliding scale insulin and gave the injections to R1. V2 said she quickly realized she had given R1 his regular sliding scale insulin when it wasn't needed and had also given 40 units. V2 said the scheduled insulin was for 40 units as well and she must have had the 40 units in her head. V2 said R1's blood glucose level was 103 and R1 did not need any sliding scale insulin. V2 said she never should have been trying to give a report to the oncoming nurse while passing medications to the residents. V2 said when passing medications to a resident, the nurses focus should be on the medications. On 8/27/24 at 9:45 AM, V5 (Certified Nursing Assistant/CNA) said she worked the day shift on 8/19/24 and saw R1 in bed most of the day but did eat lunch and supper. V5 said R1 acted tired. On 8/27/24 at 9:50 AM, V4 (Registered Nurse/RN) said she was working the day shift on 8/19/24, the day after R1 received too much insulin. V4 said R1 was tired that day but was up for his meals. V4 said R1 had one emesis in the hall as he was walking but denied feeling sick and only apologized for making a mess. On 8/27/24 at 9:55 AM, V6 (CNA) said she was working the day shift on 8/19/24 and said R1 never complained of anything but did vomit one time. R1's gait was steady and he felt bad for vomiting on the floor. On 8/27/24 at 10:06 AM, V3 (RN) said she was the nurse receiving report from V2 on the night of 8/18/24. V3 said V2 had had a bad shift and was very busy and running late with the bed time medication pass. V2 was telling me about the change in another's resident's condition as she was drawing up (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: 146114 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 146114 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lena Living Center 1010 South Logan Street Lena, IL 61048 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)