Health inspection·December 6, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review the facility failed to administer medications per physician's orders for 2 of 3 (R195 and R37) reviewed for medications given on time in a sample of 38. Residents Affected - Few Findings include: 1. R195's Physician's Order Sheet (POS), dated 11/2024 documents diagnosis included diabetes with no diagnosis of rash. 11/21/2024 Tacrolimus topical 0.1% ointment BID (twice a day) for rash on legs. 11/21/2024 Clobetasol topical 0.05% cream BID for rash. 11/21/2024 Metformin 850 milligrams (mg) BID for diabetes. R195's Medication Administration Record (MAR), dated 11/2024 documents Tacrolimus 0.1% topical ointment BID (twice a day) for rash on legs 0 documented as not given on 11/22/2024 through 11/24/2024 8:00 AM dose and 11/22/2024 through 11/26/2024 at 8:00 PM. Clobetasol 0.05% topical cream apply BID to rash 0 documented as not given at 8:00 PM on 11/22/2024, 11/26/2024 and 11/27/2024. Metformin 850 mg BID 8:00 PM dose 0 documented as not given. On 12/5/2024 at 10:30 PM V12, R195's wife stated she did not bring any medications including creams or ointments to the facility and no staff asked her to do that. 2. R37's POS, dated 11/2024 documents no diagnosis listed for anxiety. A physician's order dated, 11/9/2024 Alprazolam 0.25 mg TID (three times a day) for anxiety. R37's MAR, dated 11/2024 documents an order dated 11/5/2024 Alprazolam 0.25 mg tablet TID for anxiety 8:00 AM, 2:00 PM and 8:00 PM 0 was documented as not given on 11/11/2024 at 8:00 PM dose. On 12/5/2024 at 10:00 AM V2, DON (Director of Nurses) stated when a resident is admitted to the facility from the hospital the hospital submits prescriptions for a few days then the facility physician has to send prescriptions to the facility and if the prescription is sent STAT it usually takes the pharmacy to deliver the medication within 4-6 hours and when the medication is not send STAT if the medication is ordered before 5:00 PM the medication is usually here by 10:00 PM and when the medication is ordered after 5:00 PM the medication will be delivered to the facility at 2:00 AM. V2 stated the facility has an emergency backup medication system but it does not hold controlled medications or creams/lotions and only holds certain medications which doesn't include Metformin 850 mg. The wound nurse has prescription creams/ointments on her wound cart but staff wouldn't be able to get a hold of the wound nurse and do not have access to her wound cart at 8:00 PM. When a medication is not available at the facility staff document a 0 on the resident's MAR and then write a note as to why Page 1 of 2 145102 145102 12/06/2024 Memorial Care Center 4315 Memorial Drive Belleville, IL 62226

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the medication was not given and these missed medications were documented not available from pharmacy. On 12/5/2024 at 10:50 AM V2 stated she expects staff to follow the facility's medication administration policy and to notify nurse supervisor and the resident's provider when a physician prescribed medication is not available to see if there is an alternate medication to be administered. On 12/5/2024 at 11:19 AM V1, Administrator showed documentation V14, LPN/RN notified the afterhours telehealth provider that only prescribed patient 5 Alprazolam which he takes TID. Are you able to call in more. If not, I can try the afterhours telehealth provider again. Response was RX (physician prescribed medication) sent. There was no documentation of resident name or any other identifying information on the paper. V1 stated this was the only documentation of medications that were documented as not available from pharmacy/documented as not given for the residents and she expected staff to follow the facility's medication administration policy and to notify the nursing supervisor and the resident's provider when a medication is not available. The Facility's Administration of Medication Policy, revised 6/2023 documents purpose: to provide general guidelines for staff to follow in the administration of medications. Responsibility: it is the responsibility of all RNs, LPNs, and CMTs to understand and comply with this policy. It is the Nurse Manager's responsibility to maintain and enforce this policy. Policy: if the medication is unavailable any time, the Nursing Supervisor should be contacted and may obtain medication from the emergency drug supply or contact the physician to try to obtain an alternate order. 145102 Page 2 of 2