Inspection·August 14, 2024

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to administer medications as ordered for 1 (R93) of 5 residents reviewed during medication administration in the sample of 48. There were 27 opportunities with two errors resulting in a 7.41% error rate. Residents Affected - Few Findings include: On 08/12/24 at 09:22 AM Surveyor observed V11 (Licensed Practical Nurse) administering medications on the second floor unit. Surveyor observed V11 (LPN) administering medications to R93. On 08/12/2024 at 01:56 PM Surveyor noticed, while completing medication reconciliation, that V11 (LPN) documented in R93's MAR (Medication Administrator Record) two medications as given whereas surveyor did not observe those medications being given during medication administration task. On 08/12/24 at 02:13 PM Surveyor interviewed V11 (LPN). Surveyor asked if V11 (LPN) gave all medications to R93, V11 (LPN) said, R93 refused two. Surveyor asked if V11 (LPN) followed up with R93 and offered it again, V11 (LPN) said, I will do it right now. Surveyor established that V11 (LPN) signed out both medications as given, V11 (LPN) said, I'm sorry, let me see if R93 wants them now. Surveyor asked what should have been done this morning, upon R93's refusal, V11 (LPN) said, I should have documented it as refused when R93 refused to take two of the medications this morning. On 08/13/24 at 10:17 AM Surveyor interviewed V2 (Director of Nursing) who stated: If a resident refuses a medication, nurse should re-offer the medication in a few minutes and try to find out why the resident doesn't want to take it. The nurse should document the refusal and notify all involved parties, such as doctor and resident representative. Surveyor clarified why is it inappropriate to document that medication was given when, in fact, it was not, V2 (DON) said: The documentation is inaccurate if a nurse signs off medication as it was given but, in fact, it was not given. R93's physician order dated 11/27/2022 reads in part, Tiotropium Bromide Monohydrate Capsule 18 MCG 1 capsule inhale orally one time a day for COPD Rinse mouth with water and spit after administration due at 9:00 AM R93's physician order dated 11/27/2022 reads in part, Wixela Inhub Aerosol Powder Breath Activated 250-50 MCG/DOSE (Fluticasone- Salmeterol) 1 puff inhale orally every 12 hours related to Unspecified Asthma. Rinse mouth with H2O and spit back in cup after use due at 9:00 AM and 9:00 PM R93's MAR (Medication Administration Record) for August 2024 shows both, Tiotropium Bromide Monohydrate Capsule and Wixela Inhub Aerosol Powder documented as given on 08/12/2024 at 9:00 AM by V11 (LPN). (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 5 Event ID: 145171 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 145171 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Northbrook 270 Skokie Highway Northbrook, IL 60062 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)