Health inspection·January 2, 2025

F 0759 Ensure medication error rates are not 5 percent or greater. 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 administer medications as ordered by the physician. There were 27 opportunities with 3 medication errors resulting in a 11.11% medication error rate. Residents Affected - Few This applies to 1 of 3 residents (R2) reviewed for medication administration in the sample of 3. The findings include: R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, pulmonary hypertension, peripheral vascular disease, hypertensive chronic kidney disease, chronic pulmonary embolism, hypertension, and anemia. R2's medication care plan dated December 21, 2022, showed, [R2] is on diuretic therapy. The care plan continued to show multiple interventions dated December 21, 2022, including Administer diuretic medications as ordered by physician. Monitor for side effects and effectiveness every shift. R2's Order Summary Report, dated December 31, 2024, at 11:44 AM, showed an order, dated December 20, 2022, for Spironolactone tablet 25 mg, give 50 mg by mouth one time a day for diuretic. The Report continued to show an order, dated September 4, 2024, for Vitamin D3 tablet 1000 unit, give 1000 unit by mouth one time a day for vitamin D insufficiency. The Report showed an order, dated August 29, 2024, for Lidocaine External patch, apply to left knee are topically one time a day for pain, Lidocaine 4% pain patch to left knee. On December 31, 2024, at 9:40 AM, V4 (RN/Registered Nurse) prepared the following medications for R2: one tablet aspirin 81 mg (milligrams), one tablet docusate 100 mg, two tablets potassium chloride 10 mEq (milliequivalents), one tablet spironolactone 25 mg, one tablet metoprolol 100 mg, one tablet vibegron 75 mg, one tablet vitamin D3 2000 units, one tablet diphenhydramine 25 mg, and one lidocaine patch. V4 said she had nine pills to administer to R2. At 9:50 AM, V4 administered R2's medications. At 9:54 AM, V4 removed a lidocaine patch from R2's left lower back and placed the new patch on R2's left lower back. On December 31, 2024, at 11:33 AM, V2 (DON/Director of Nursing) said it is the expectation for a nurse to ensure the correct medication dose is administered to a resident. V2 continued to say V4 should have administered the correct doses of spironolactone and vitamin D3 to R2. V2 said V4 should have followed physician orders and applied the lidocaine patch to the prescribed area of the left knee. The facility's policy titled Medication Administration, dated August 1, 2024, showed, Policy and Procedure, Subject: Medication Administration, Intent: All medications are administered safely and Page 1 of 2 145045 145045 01/02/2025 Pearl of Naperville, The 200 Martin Avenue Naperville, IL 60540

F 0759 Level of Harm - Minimal harm or potential for actual harm appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. Level of Responsibility: RN, LPN (Licensed Practical Nurse). Guideline: .5. Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. 6. Read each order entirely. 7. Remove medication from drawer and read label three times; when removing from drawer, before pouring and after pouring . Residents Affected - Few 145045 Page 2 of 2