Health inspection·August 15, 2023

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's schedule II narcotic was free from misappropriation for two of three residents (R1 and R3) reviewed for misappropriation of property in a sample of three. Residents Affected - Few Findings include: The facility's Abuse Prevention Program, revised 11/28/16, documents that it is the right of the resident to be free from abuse, neglect, misappropriation of resident property, and exploitation. This form documents that misappropriation of resident property means deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. R1's current Physician Order Sheet, documents for R1 to take Hydrocodone (schedule II)-Acetaminophen 5mg (milligrams)325mg every six hours as needed. The facility's shipment details invoice details sheet documents that 30 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered on 7/28/23 for R1. There is no Controlled Substance Proof of Use sheet in R1's medical record. R3's Physician Order Sheet, dated 8/1/23-8/11/23, documents to take Hydrocodone-Acetaminophen 5mg-325mg every six hours. The facility's pharmacy shipment details sheet documents that on 8/2/23 60 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered to the facility. R3's Controlled Substance Proof of Use, dated 8/2/23, documents that the quantity delivered was 60 tablets, but only 30 tablets are accounted for. This form documents that 14 tablets of R3's Hydrocodone-acetaminophen 5mg-325mg were signed out as given at the facility and 16 were sent home with R3 at the time of her discharge on [DATE]. Thirty of R3's Hydrocodone-Acetaminophen 5mg-325mg were not accounted for. On 8/15/23 at 10:30am, V2, Director of Nursing, stated that R1 and R3's Hydrocodone-Acetaminophen 5mg-325mg tablets could be accounted for. On 8/15/23 at 1:00pm, V1, Administrator, verified that Controlled Substance Proof of Use could not be found for R1 and R3. Page 1 of 3 145266 145266 08/15/2023 Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility establish a system for the receipt and reconciliation of controlled drugs for two of three residents (R1 and R3) reviewed for controlled drugs in a sample of three. Findings include: The facility's Controlled Substances policy, revised 10/06, that all drugs listed as schedule II are subject to specified handling, storage, disposal, and record keeping. This form also documents that the drugs in Schedule II will be counted and reconciled by the nurse coming on duty with the nurse that is going off duty. The facility's shipment details invoice details sheet documents that 30 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered on 7/28/23 for R1. There is no Controlled Substance Proof of Use sheet in R1's medical record. The facility's pharmacy shipment details sheet documents that on 8/2/23, 60 tablets of Hydrocodone-Acetaminophen 5mg-325mg were delivered to the facility for R3. R3's Controlled Substance Proof of Use, dated 8/2/23, documents that the quantity delivered was 60 tablets, but only 30 tablets are accounted for. This form documents that 14 tablets of R3's Hydrocodone-acetaminophen 5mg-325mg were signed out as given at the facility and 16 were sent home with R3 at the time of her discharge on [DATE]. Thirty of R3's Hydrocodone-Acetaminophen 5mg-325mg were not accounted for. On 8/15/23 at 10:30am, V2, Director of Nursing, stated that R1 and R3's Hydrocodone-Acetaminophen 5mg-325mg tablets could not be accounted for. On 8/15/23 at 1:00pm, V1, Administrator, verified that Controlled Substance Proof of Use could not be found for R1's Hydrocodone-Acetaminophen 5mg-325mg delivered on 7/28/23. V1 also stated that 30 of R3's Hydrocodone-Acetaminophen 5mg-325mg could not found. 145266 Page 2 of 3 145266 08/15/2023 Fondulac Rehabilitation and Health Care Center 901 Illini Drive East Peoria, IL 61611

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review the facility failed to ensure the privacy of medical records for two of three residents (R1, R3) reviewed for medical records in a sample of three. Residents Affected - Few Findings include: The facility's Notice of Privacy Practices, undated, documents that the facility is required by law to maintain the privacy of your health information and to provide to you and your representative this notice of duties and privacy practices. R1's Controlled Substances Proof of Use form, documents R1's full name and place of residents. This form documents for R1 to take Hydrocodone-Acetaminophen 5mg (milligrams) 325mg tablets every six hours as needed for pain. R3's Controlled Substances Proof of Use form, documents R3's full name and place of residency. This form also documents for R3 to take Hydrocodone-Acetaminophen 5mg-325mg every six hours. On 8/14/23 at 10:45am, V4, Detective, verified that during the autopsy of V3, Licensed Practical Nurse, two cards of Hydrocodone-Acetaminophen 5-325mg, along with the reconciliation forms were found in V3's upper breast pocket of her scrubs. The reconciliation forms did have R1 and R3's names, dosages, and frequency of the medication. On 8/15/23 at 1:00pm, V1, Administrator, verified that personal information of the residents is not to be taken out of the facility. 145266 Page 3 of 3