Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
interview and record review the facility failed to transcribe a resident's admission medication orders in a
manner to prevent a significant medication error. This failure resulted in R1 developing hypotension (low
blood pressure) and dizziness after receiving eight (8) doses of a diuretic medication (water-pill), one pill
per day, from [DATE]-[DATE], instead of PRN (as needed), as shown per R1's hospital discharge orders.
This failure applies to 1 of 6 residents (R1) reviewed for medication administration and significant
medication errors in the sample of 6.
Residents Affected - Few
The findings include:
A facility incident report dated [DATE] showed R1 was admitted to the facility on [DATE], from a local
hospital. The report showed R1 began complaining of dizziness on [DATE]. The report showed R1's
Metolazone (diuretic medication) was entered incorrectly as scheduled, instead of daily as needed, for
weight gain greater than 5 pounds. Physician notified and order received for STAT labs and to push fluids .
R1's hospital History and Physical report dated [DATE] showed R1 had a significant history of CHF
(congestive heart failure), dilated cardiomyopathy, and hypertension (high blood pressure). The report
showed R1's blood pressure as 136/80.
R1's hospital discharge orders dated [DATE] showed R1 was admitted to the facility with a physician order
for Metolazone (diuretic medication) 5mg (milligrams): Take one tablet by mouth daily, as needed, for a
weight gain greater than 5 pounds.
A facility's physician order for R1, dated [DATE], showed the Metolazone medication was incorrectly
ordered as Metolazone oral tablet 5 mg: Give 1 tablet by mouth one time a day (at 9:00 AM) for
edema/weight gain.
R1's [DATE] Medication Administration Record showed R1 was administered Metolazone, 5 mg (1 tablet)
daily, from [DATE]-[DATE].
R1's progress note dated [DATE] showed R1 was assessed by staff due to her complaint of dizziness. R1's
blood pressure was checked. R1 was hypotensive with a blood pressure of 94/52. R1 was given fluids. R1's
physician was notified. During this incident, R1's medications were reviewed. R1's Metolazone medication
was found to have been incorrectly transcribed/ordered by the facility.
On [DATE] at 10:25 AM, V8 (Family of R1) stated, I was there (on [DATE]) when (R1) had an episode but,
she also had a similar episode the day before ([DATE]) where (R1) got pale, her blood pressure
(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:
146118
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
146118
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/10/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Prairieview at the Garlands
6000 Garlands Lane
Barrington, IL 60010
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 - Actual harm
Residents Affected - Few
dropped, and she felt faint. My sister was there for that one. When I was there, it all happened so quick. It
was kind of a frantic scene. (R1) suddenly got pale, felt faint, and her blood pressure dropped. I was scared.
I thought she was going to die. She thought she was going to die. (R1) kept trying to tell us no CPR, so we
didn't do CPR (cardiopulmonary resuscitation) if it came to that. Staff came running in. They laid her flat.
They tried to get her to drink water. That's when they found the medication error. I am just so thankful she
survived. I saw my dad die. I couldn't go through that again.
R1's Weights and Vitals Summary record for [DATE] was reviewed. It showed R1 did have an episode of
hypotension on [DATE] at 11:30 AM, as reported by V8 (Family of R1). R1's blood pressure dropped to
78/38 at that time. No progress notes or other documentation was noted related to R1's symptoms and
hypotension on [DATE].
On [DATE] at 9:54 AM, V1 Administrator stated she did not know R1 had an episode of hypotension and
dizziness on [DATE].
On [DATE] at 12:00 PM, V2 Director of Nursing stated the facility has a double check process in place to
ensure a new admission's medication orders are transcribed correctly from the resident's hospital
discharge medication orders. V2 stated, The nurse that admits the resident, transcribes the admission
medication orders into the computer, from that resident's hospital discharge orders. The oncoming night
nurse is supposed to double check to make sure the orders were entered correctly. Unfortunately, in (R1's)
case, that did not happen. (V5 Registered Nurse/RN) incorrectly transcribed (R1's) Metolazone order. The
night nurse that took over for (V5) didn't double check (R1's) admission orders. V2 stated she did not know
R1 had an episode of hypotension and dizziness on [DATE].
On [DATE], two attempts to contact V5 RN, via phone, for an interview were unsuccessful. V1 Administrator
stated V5 was no longer employed by the facility.
On [DATE] at 10:45 AM, V6 (Pharmacist) stated, Metolazone is a medication used to help residents, with
CHF, get rid of extra fluid. I see here in the computer that (R1's) admission order for Metolazone was sent
us (from the facility) with an order for the medication to be given daily, not PRN (as needed). It wasn't
transcribed correctly. If the medication is not given as ordered, it can cause dehydration, low blood
pressure, and possibly cause someone to pass out. I see she (R1) is also on Lasix (another diuretic
medication). If someone is on both Metolazone and Lasix, it can be potentially dangerous for someone if
not given correctly.
On [DATE] at 11:02 AM, V7 (R1's Physician) stated, (R1) was seen by cardiology in the hospital. She has
bad CHF. She was supposed to get the Metolazone PRN, not daily. If the medication is not given correctly, it
can cause dehydration, low blood pressure, and feeling faint. If not treated, it could cause someone to pass
out and become unresponsive.
The facility's Medication on Admission, Readmission, and Discharge policy dated [DATE] showed,
Medication orders upon admission, readmission, and discharge in skilled nursing are to be entered by the
admission nurse, verified by the physician, pharmacy and oncoming nurse for the next shift . The oncoming
nurse for the next shift reviews the medication orders entered in the electronic medical record to prevent
medication errors .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146118
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
FAQ · About this visit
Common questions about this visit
What happened during the April 10, 2024 survey of PRAIRIEVIEW AT THE GARLANDS?
This was a inspection survey of PRAIRIEVIEW AT THE GARLANDS on April 10, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PRAIRIEVIEW AT THE GARLANDS on April 10, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.