Health 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). Page 1 of 5 145171 145171 08/14/2024 Elevate Care Northbrook 270 Skokie Highway Northbrook, IL 60062

F 0759 Level of Harm - Minimal harm or potential for actual harm The policy provided by the facility MAC Rx Pharmacy Policies and Procedures Manual dated 10/25/2024 reads in part, Refusals of Medications: 5) Medication refusal must be reported to the prescriber after (XX) number of doses are refused and there must be documentation of prescriber notification of such. Documentation (including electronic): 1) At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. Residents Affected - Few 145171 Page 2 of 5 145171 08/14/2024 Elevate Care Northbrook 270 Skokie Highway Northbrook, IL 60062

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their medication storage policy by not ensuring an insulin vial was properly labeled and stored in accordance with accepted professional practice. This failure affected 6 residents with orders for Lispro (Human) insulin (R97, R105, R124, R146, R187, R193) of 6 residents reviewed for medication label and storage. Findings include: On [DATE] at 11:28 AM, reviewed medication storage and labeling task for 1 east med cart with V14 (Registered Nurse) and observed an opened and unlabeled vial of lispro insulin that was half filled. When asked which resident the insulin vial belonged to, V14 (RN) said he did not know. When asked if the insulin vial was currently being used and if the vial should be stored in the refrigerator when not in use, V14 (RN) said yes. V14 (Registered Nurse) then said the insulin vial should have been properly labeled with the resident's name, dated when opened with the date of expiration indicated to avoid staff administering expired insulin to a resident. Requested list of residents on unit 1 east who receive lispro insulin. V1 (Administrator) provided a list of dated [DATE] that showed the following residents: R97, R105, R124, R146, R187, and R193. Active physician orders reconciled with medication administration records for above listed residents that revealed an active order for lispro that is being administered daily as follows: 1. R97's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject subcutaneous (under the skin) five times a day for diabetes as per sliding scale: if 0 - 69 = 0 Units Give glucose and notify physician; 70 - 149 = 0 Units; 150 - 199 = 1 Unit; 200 - 249 = 3 Units; 250 - 299 = 5 Units; 300 - 349 = 7 Units; 350 > give 8 units and notify physician. Medication administration records for last 60 days (06/2024 through [DATE]) showed daily administrations of lispro insulin for R97. 2. R105's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject subcutaneous (under the skin) before meals for per clinical parameters related to diabetes, inject as per sliding scale: if 0 - 69 = 0 Units Give glucose and notify physician; 70 - 149 = 0 Units; 150 - 199 = 1 Unit; 200 - 249 = 2 Units; 250 - 299 = 3 Units; 300 - 349 = 4 Units; 350 > give 5 units and notify physician. Medication administration records for last 60 days (06/2024 through [DATE]) showed daily administrations of lispro insulin for R105 as of start date of [DATE]. 3. R124's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject subcutaneous (under the skin) before meals and at bedtime, inject as per sliding scale: if 150 - 199 = 1 units; 200 - 249 = 2 units ; 250 - 299 = 3 units; 300 - 349 = 4 units more or = 350 milligram (mg)/deciliter (dl) 5 units call primary medical doctor (PMD) for blood sugar (bs) more than 400 and call PMD. Less than 60 mg/dl call PMD. 145171 Page 3 of 5 145171 08/14/2024 Elevate Care Northbrook 270 Skokie Highway Northbrook, IL 60062

F 0761 Level of Harm - Minimal harm or potential for actual harm Medication administration records for last 60 days (06/2024 through [DATE]) showed daily administrations of lispro insulin for R124. 4. R146's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject 3 units subcutaneous (under the skin) every 6 hours for diabetes. Residents Affected - Some Medication administration records for last 60 days (06/2024 through [DATE]) showed daily administrations of lispro insulin for R146. 5. R187's active physician orders showed order with start date of [DATE] for Humalog Solution 100 unit/ml (Insulin Lispro (Human), inject subcutaneous (under the skin) before meals and at bedtime for diabetes AND Inject 3 unit subcutaneously before meals and at bedtime related to diabetes, inject as per sliding scale: if 0 - 69 = 0 Units Give glucose and notify physician; 70 - 149 = 0 Units; 150 - 199 = 1 Unit; 200 - 249 = 2 Units; 250 - 299 = 3 Units; 300 - 349 = 4 Units; 350 > give 5 units and notify physician. Medication administration records for last 60 days (06/2024 through [DATE]) showed daily administrations of lispro insulin for R187 as of start date of [DATE]. 6. R193's active physician orders showed order with start date of [DATE] for Insulin Lispro 100 unit/ml solution, inject subcutaneous (under the skin) one time a day with meal related to type 2 diabetes mellitus, inject as per sliding scale: if 150 - 199 = give 1 unit and notify physician; 200 - 249 = give 2 units; 250 - 299 = give 3 units; 300 - 349 = give 4 units; 350 > give 5 units and notify physician. Medication administration records for last 60 days (06/2024 through [DATE]) showed daily administrations of lispro insulin for R193 as of start date of [DATE]. *Noted R193's discontinued order on [DATE] for Insulin Lispro 100 unit/ml solution with start date of [DATE] to inject subcutaneous (under the skin) before meals related to type 2 diabetes mellitus, inject as per sliding scale: if 0 - 69 = give 0 units and notify physician; 70 - 149 = give 0 units; 150 - 199 = give 1 unit; 200 - 249 = give 2 units; 250 - 299 = give 3 units; 300 - 349 = give 4 units; 350> give 5 units and notify physician. Medication administration records for last 60 days (06/2024 through [DATE]) showed daily administrations of lispro insulin for R193 as of start date of [DATE]* On [DATE] at 11:55 AM, V2 (Director of Nursing) said all insulin vials should be dated upon opening and should include residents name and expiration date. Medication storage policy last revised [DATE] reads in part: to ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles. Once any medication or biological package in opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. Facility should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damaged or missing labels. Facility should ensure that medications and biologicals are stored at their appropriate temperatures according to United States Pharmacopeia guidelines for temperature ranges. 145171 Page 4 of 5 145171 08/14/2024 Elevate Care Northbrook 270 Skokie Highway Northbrook, IL 60062

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Vials and Ampules of Injectable Medications policy effective [DATE] reads in part: vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. The date opened and the initials of the first person to use the vial are recorded on the multidose vials. Medication in multidose vials may be used until the manufacturer's expiration date/for the length of time allowed by the state law/according to facility policy/ for thirty days. USP <797> guidelines recommend discarding multidose vials at 28 days after opened. Reviewed lispro manufacturer instructions for use after vials have been opened that indicated to store opened vials in the refrigerator or at room temperature up to 86°F (30°C) for up to 28 days and throw away all opened vials after 28 days of use, even if there is insulin left in the vial. 145171 Page 5 of 5