St Clara's Rehab & Senior Care
ST CLARA'S REHAB & SENIOR CARE in LINCOLN, IL — inspection on August 23, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Glucose Testing) before meals and at bedtime.
Diagnosis Type II Diabetes Mellitus.R2's MARs dated 6/1/25 through 8/22/25 document R2's blood glucose testing was not obtained as ordered by the physician on 6/29/25 at 11:30 AM and 7/2/25 at 5:00 PM.On 8/23/25 at 10:15 AM V2 (Director of Nursing) verified R2's blood glucose was not obtained as ordered on 6/29/25 at 11:30 AM and 7/2/25 at 5:00 PM.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
St Clara's Rehab & Senior Care
1450 Castle Manor Drive Lincoln, IL 62656
SUMMARY STATEMENT OF DEFICIENCIES
Based on record review and interview the facility failed to administer insulin as ordered for one of three residents (R1) reviewed for medication errors in the sample of three.Findings include:The facility's Medication Administration policy dated 1/11/2010 documents, Objective: To provide accuracy during medication pass to assure quality care for residents.
Policy: It is the policy of the facility to accurately administer medication following physician's orders.
Medications should be charted during the medication pass in a consistent manner before going to the next resident.R1's Physician Order Summary Reports and MARs (Medication Administration Records) dated 6/1/25 through 8/22/25 document, Start Date 6/13/25 Insulin Aspart insulin inject 15 units subcutaneously before meals related to Type II Diabetes Mellitus.
Insulin Apart insulin per sliding scale subcutaneously before meals and at bedtime related to Type II Diabetes Mellitus. If 0-150 (blood glucose) = (equals) 0 units. 151-200 =2 units. 201-250 = 4 units. 251-300 = 6 units. 301-350 = 8 units. 351-400 = 10 units.
Start Date 7/22/25 Humalog insulin 15 units subcutaneously before meals for Diabetes Mellitus.R1's MARs dated 6/1/25 through 8/22/25 document R1's Insulin Aspart 15 units was not administered as ordered by the physician on 6/18/25 at 4:30 PM, 6/24/25 at 4:30 PM, 6/29/25 at 4:30 PM, 7/12/25 at 4:30 PM, and 7/13/25 at 4:30 PM. R1's MARs dated 6/1/25 through 8/22/25 document R1's blood sugar on 7/12/25 was 188 and R1's Aspart insulin 2 units sliding scale was not administered at 4:30 PM as ordered by the physician. R1's MARs dated 6/1/25 through 8/22/25 document R1's Humalog insulin 15 units was not administered as ordered by the physician on 7/27/25 at 5:30 PM, 8/9/25 at 5:30 PM, 8/13/25 at 5:30 PM, and 8/19/25 at 5:30 PM.On 8/22/25 at 1:20 PM V5 (R1's Physician) stated, (R1) should receive her insulin as ordered.On 8/23/25 at 10:15 AM V2 (Director of Nursing) verified that according to R1's MARs R1 did not receive Aspart insulin as ordered on 6/18/25 at 4:30 PM, 6/24/25 at 4:30 PM, 6/29/25 at 4:30 PM, 7/12/25 at 4:30 PM, and 7/13/25 at 4:30 PM, and R1 did not receive Humalog insulin as ordered 7/27/25 at 5:30 PM, 8/9/25 at 5:30 PM, 8/13/25 at 5:30 PM, and 8/19/25 at 5:30 PM. V2 also confirmed that R1 not receiving her insulin as ordered is considered a medication error.
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