Inspection·September 15, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their facility policy, and ensure that a resident had a physician order for medications that were stored at the bedside along with an assessment for self-administration of medications for two of four residents (R2 and R3) reviewed for self-administration of medication in a sample of four. Residents Affected - Few Findings include: The facility's Self-Administration of Medication Policy dated 8/2017 documents it is the responsibility of the Interdisciplinary Team/IDT to assess and determine if those residents who request to self-medicate can do so. This same policy states, Procedure: A resident may not be permitted to administer or retain any medication in his/her room unless so ordered by the physician. 2. Should the resident's attending physician permit the resident to administer his/her medications, the following conditions will apply: A. The IDT will evaluate the resident's cognitive, physical, and visual ability to self-medicate using the Assessment Form for Self-Administration of Medications. B. The Care Plan will reflect the program of each resident. C. Storage of medication may be in the resident's room or in the locked medication cart. D. Only the medications permitted for self-administration shall be left at the bedside. 1. R2's Medication Review Report documents R2 with a diagnosis of Chronic Obstructive Pulmonary Disease/COPD and an order with a start date of 7/17/23 for Symbicort Inhalation Aerosol 160-4.5 MCG/ACT (Micrograms per Actuation). Two puffs inhale orally two times a day for COPD. R2's Minimum Data Set/MDS assessment dated [DATE] documents R2 as cognitively intact. On 9/14/23 at 1:04 PM, R2 was sitting up in R2's bed with oxygen via nasal cannula in place. R2 was alert and able to answer questions well. R2's bedside table was pulled across the bed in front of R2. Lying on top of the bedside table was R2's Symbicort inhaler. At this time, R2 stated that R2 keeps R2's Symbicort inhaler in R2's room so that R2 can use the inhaler when needed. R2 stated R2 has always kept his inhaler in R2's room and that R2 notifies the nursing staff when R2 uses R2's inhaler. R2 stated R2 has COPD and stated the Symbicort Inhaler helps R2 breathe better. As of 9/14/23 at 1:00 PM, R2's medical records did not contain a physician order for R2 to keep medications at R2's bedside and did not contain an assessment for self-administration of medications. R2's Care Plan did not contain documentation regarding R2's ability to self-administer medications or to keep medications at R2's bedside. On 9/14/23 at 1:46 PM, V2 (Director of Nursing) verified the presence of R2's Symbicort Inhaler in (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 4 Event ID: 145039 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 145039 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Accolade Healthcare of Peoria 5600 Glen Elm Drive Peoria, IL 61614 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)