Health inspection·July 11, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure resident's prescribed medication was available for one (R1) of three residents reviewed for medication administration in a sample of three. Findings include: The facility's Medication Administration policy, revised 11/18/17, documents Procedure: 21. If the medication is not available for a resident, call the pharmacy and notify the physician when the drug is expected to be available. Like medications are not to be Borrowed from one resident to another. R1's current Physician Order Sheet/POS documents an order for Zolpidem Tartrate Oral Tablet 10mg (milligrams) give one tablet by mouth at bedtime related to insomnia. R1's current Care Plan documents a focus of (R1) is on sedative/hypnotic therapy related to insomnia, with interventions including but not limited to Administer Sedative/Hypnotic medications as ordered by physician. On 7/9/24, at 12:36pm, R1 sat in his room and stated he did not receive his Ambien (Zolpidem) two or three times in June due to an ordering issue. R1 said I did not sleep well without it and was up in the middle of the night. I have an anxiety issue and am very regimented. They have no system in place to order meds. R1's Medication Administration Record/MAR, dated June 2024, was signed by V8 Licensed Practical Nurse/LPN and documents R1 did not receive Zolpidem on 6/9/24 and 6/10/24 due to the drug being unavailable. R1's Progress Notes, dated 6/9/24 and 6/10/24, document R1's medication (Zolpidem) was on order. On 7/11/24, at 10:44am, V8 LPN stated I believe it was a weekend when (R1) didn't get his Ambien. It was not available .At the time I was not aware of the narcotic emergency box only the stock med emergency box. On 7/11/24, at 1:30pm, V4 LPN showed this writer the facility's back up Emergency kit in the med room. This kit contained Zolpidem Tartrate (Ambien) 5mg tabs Quantity of 6. V4 confirmed that if a resident was out of Ambien, it could be taken from the kit by calling pharmacy for the code to open it. Page 1 of 2 145239 145239 07/11/2024 Goldwater Care Peoria Heights 5533 North Galena Road Peoria Heights, IL 61614

F 0755 Level of Harm - Minimal harm or potential for actual harm On 7/11/24, at 2:07pm, V2 Director of Nursing/DON stated I didn't know (R1) missed the two doses until June 11 when I came in early, and the night shift nurse told me. I think what failed is that earlier that week I told (V4 LPN) to order the CIIs (Schedule 2 Controlled Substances). (V4) said she thought I meant only the meds that (V4) needed to give. I had to educate (V4) on this incident to go through the carts and order all of them. V2 confirmed that. Residents Affected - Few the pharmacy would not have provided a code for the emergency box since they needed a new signed script for R1's Ambien. 145239 Page 2 of 2