Health inspection·September 16, 2024

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 Based on interview and record review, the facility failed to protect residents from misappropriation of resident property for nine residents (R7, R8, R9, R10, R11, R12, R13, R14 and R15) of nine residents reviewed for missing medications, in a sample of 15. Residents Affected - Some FINDINGS INCLUDE: The facility policy, Abuse Prevention and Reporting, dated (reviewed) 08/2023 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The facility Preliminary 24-Hour Abuse Investigation Report dated 8/30/24 documents, We (facility) have received all allegation (of) Theft. On 8/29/24 (the facility) made aware of alleged misappropriation of resident property. Investigation initiated. Staff member identified (V6/RN) and suspended pending investigation. Follow up report will be sent. The (facility) Count of Missing Medication form, provided by V9/Regional Director of Operations documents, R11 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/26/24- missing: R14 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/19/24- missing and R14 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/1/24- missing and R14 (Pharmacy) dispensed 30 Norco 5/325 MG tablets on 7/18/24- missing; R15 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 7/30/24- missing and R15 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/9/24- missing; R13 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 7/6/24- missing and R13 (Pharmacy) dispensed 60 Norco 5/325 MG tablets- missing; R12 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 7/22/24- missing and (Pharmacy) dispensed 58 Norco 5/325 MG tablets on 8/26/24- missing; R10 (Pharmacy) dispensed 120 Norco 5/325 MG tablets- missing; R9 (Pharmacy) dispensed 90 Oxycontin 5/325 MG tablets on 8/15/24- missing; R7 (Pharmacy) dispensed 60 Tramadol 50 MG tablets on 7/22/24- missing; R8 (Pharmacy) dispensed 120 Norco 5/325 MG tablets on 8/13/24- missing. The facility Final Abuse Investigation Report, Original Allegation: Misappropriation of Property, dated Initial Report: 8/30/24, Final Report: 9/5/24 documents, Facts Determined: On 8/29/24 at approximately 12 (12:00) P.M., (facility) made aware of alleged misappropriation of medication occurring by alleged perpetrator (V6/Former Employee Registered Nurse) at facilities (V6) had been contracted at as agency staff. Resident's (R7, R8, R9, R10, R11, R12, R13, R14 and R15) Medical Doctor, local police department and Ombudsman were notified of the allegation. Alleged perpetrator (V6) identified and suspended pending investigation. All residents with pain medication assessed, no change in pain status noted. Both residents and staff interviews were initiated. Conclusion and Action Taken: IDT Page 1 of 4 145319 145319 09/16/2024 Arc at El Paso 555 East Clay El Paso, IL 61738

F 0602 Level of Harm - Minimal harm or potential for actual harm (Intra Disciplinary Team) met to discuss the investigation and completed education with clinical staffing regarding Narcotics. Audit conducted revealing cards of medication that could not be accounted for. Residents that were affected were reimbursed by facility. Education ongoing with all clinical nursing staff regarding Narcotic Logs. The facility will continue to audit logs for Narcotic compliance. Concerns with alleged perpetrator (V6) shared with (State) Professional Regulation (Department). Residents Affected - Some On 9/12/24 at 11:50 A.M., V1/Administrator stated, We hired (V6/Former employee Registered Nurse) on 7/31/24. (V6) had worked here through the Agency a couple of times in July (2024) and was a good nurse. The last day (V6) worked was 8/27/24. On 8/29/24 an officer from the State Attorney General's office came in and reported to us that (V6) was under investigation at multiple nursing homes where (V6) was working through Agency, for narcotic diversion. At that time, we were not aware of any diversion going on in our building. We ended up terminating (V6) due to (V6) not participating in the investigation. We did our own investigation and discovered we had many missing narcotics. On 9/13/24 at 9:50 A.M., V9/Regional Director of Operations stated, I was the one responsible for conducting the investigation onto the missing narcotics for this facility. I went back from June (2024) through August (2024). I discovered that during the days that (V6) worked, (V6) was able to misappropriate full (medication) cards of narcotics when our local pharmacy made their delivery, by not following our policy. During my investigation, it was determined that there were 898 missing narcotic pills, from nine different facility residents (R7-R15). 145319 Page 2 of 4 145319 09/16/2024 Arc at El Paso 555 East Clay El Paso, IL 61738

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. Based on interview and record review, the facility failed to keep medications secure for nine residents (R7, R8, R9, R10, R11, R12, R13, R14 and R15) of nine residents reviewed for medication storage, in a sample of 15. The facility policy, Narcotic/Controlled Substances- Counting, dated (reviewed) 11/2023 directs staff, To count controlled substances with a partner and to verify the accuracy of the log sheets. General Guidelines: Always participate in the counting of the controlled substances at the beginning and ending of your shift. If you do not observe the medication that you sign as being present, you may be implicated if the medications are later missing. Follow your facilities specific guidelines and use their specific log sheet. The facility form, Shift Change Controlled Substance Inventory Count Sheet directs staff, Nurse coming on to shift must verify count of all controlled substances with nurse coming off shift or any time the medication cart keys are exchanged. Nurses must count total (number) of cards/containers and total (number) count sheets, both for individual residents and applicable contingency supplies with controlled drugs. Nurses must verify actual drug counts (number of tablets, capsules, patches, vials, etc.) against each individual resident count sheet. Any discrepancies must be reported immediately to director of nursing or nursing supervisor. Every controlled substance medication and count sheet added or removed from the medication cart MUST be documented below. This same form contains an area that directs staff, Ending balance of cards/containers from previous shift __, Ending balance of Count Sheets from previous shift __. Verified by Nurse 1 and Nurse 2. R7's July 2024 Physician Order Sheet includes the following diagnoses: Peripheral Vascular Disease, Pain. Also included are the following medication orders: Tramadol 50 MG (Milligrams) Give 50 MG by mouth every 12 hours for pain. R8's July 2024 Physician Order Sheet includes the following diagnoses: Pain in Left Shoulder and Primary Osteoarthritis in Knee. Also included are the following medication orders: Hydrocodone-Acetaminophen 10/325 MG Give one tablet by mouth every 12 hours for left shoulder pain and Hydrocodone-Acetaminophen 10/325 MG Give one tablet by mouth every 4 hours as needed for moderate to severe pain. R9's Physician Order Sheet, dated August 2024 includes the following diagnoses: Aftercare Following Joint Replacement Surgery, Primary Osteoarthritis of Right Knee, Presence of Right Artificial Joint, Presence of Left Artificial Hip Joint and Intervertebral Disc Degeneration of Lumber Region. Also included are the following medication orders: Oxycodone 5/325 MG Give one tablet by mouth every 4 hours as needed for moderate to severe pain. R10's August 2024 Physician Order Sheet includes the following diagnoses: Radiculopathy, Pain in Right Knee, Internal Derangement of Knee, Osteoarthritis of Knee and Encounter for Orthopedic Aftercare. Also included are the following medication orders: Hydrocodone-Acetaminophen 5/325 MG Give one tablet by mouth every 4 hours as needed for severe pain; Tramadol 50 MG Give one tablet by mouth every 6 hours as needed for severe pain. R11's August 2024 Physician Order Sheet includes the following diagnosis: Surgical Aftercare Following Surgery on the Nervous System. Also included are the following medication orders: 145319 Page 3 of 4 145319 09/16/2024 Arc at El Paso 555 East Clay El Paso, IL 61738

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Hydrocodone-Acetaminophen 5/325 MG Give one tablet by mouth every 6 hours as needed for severe pain. R12's July 2024 Physician Order Sheet includes the following diagnoses: Paraplegia, Sciatica and Multiple Sclerosis. Also included are the following medication orders: Hydrocodone-Acetaminophen 5/325 MG Give one tablet by mouth every 6 hours as needed for back pain and Hydrocodone-Acetaminophen 5/325 MG Give two tablets by mouth every 6 hours as needed for back pain related to sciatica. R13's July 2024 Physician Order Sheet includes the following diagnoses: Polyosteoarthritis, S/P Fracture of Left Femur and Low Back Pain. Also included are the following medication orders: Hydrocodone-Acetaminophen 5/325 MG Give one tablet by mouth at bedtime for back pain; Hydrocodone-Acetaminophen 5/325 MG Give one tablet by mouth every 6 hours as needed for pain and Hydrocodone-Acetaminophen 5/325 MG Give one tablet by mouth in the morning for severe right knee pain. R14's July 2024 Physician Order Sheet includes the following diagnoses: Fibromyalgia, Osteoarthritis, Polyneuropathy, Low Back Pain, Lumbago with Sciatica on Left Side, Polymyalgia Rheumatica and Spinal Stenosis Lumbosacral Region. Also included are the following medication orders: Hydrocodone-Acetaminophen 5/325 MG Give one tablet every 6 hours as needed for pain; Hydrocodone-Acetaminophen 5/325 MG Give one tablet by mouth two times a day for pain. R15's July 2024 Physician Order Sheet includes the following diagnosis: Pain. Also included are the following medication orders: Morphine Sulfate Oral Solution 20 MG/ML (Milliliter) Give 10 MG by mouth every one hour as needed for pain or shortness of breath; Hydrocodone-Acetaminophen 5/325 MG Give one tablet by mouth three times a day for pain; Hydrocodone-Acetaminophen 5/325 MG Give one tablet every 6 hours as needed for pain. The (facility) Count of Missing Medication form, provided by V9/Regional Director of Operations documents, R11 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/26/24- missing: R14 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/19/24- missing and R14 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/1/24- missing and R14 (Pharmacy) dispensed 30 Norco 5/325 MG tablets on 7/18/24- missing; R15 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 7/30/24- missing and R15 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 8/9/24- missing; R13 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 7/6/24- missing and R13 (Pharmacy) dispensed 60 Norco 5/325 MG tablets- missing; R12 (Pharmacy) dispensed 60 Norco 5/325 MG tablets on 7/22/24- missing and (Pharmacy) dispensed 58 Norco 5/325 MG tablets on 8/26/24- missing; R10 (Pharmacy) dispensed 120 Norco 5/325 MG tablets- missing; R9 (Pharmacy) dispensed 90 Oxycontin 5/325 MG tablets on 8/15/24- missing; R7 (Pharmacy) dispensed 60 Tramadol 50 MG tablets on 7/22/24- missing; R8 (Pharmacy) dispensed 120 Norco 5/325 MG tablets on 8/13/24- missing. On 9/13/24 at 9:50 A.M., V9/Regional Director of Operations stated, I was the one responsible for conducting the investigation onto the missing narcotics for this facility. I went back from June (2024) through August (2024). I discovered that during the days that (V6) worked, (V6) was able to misappropriate full (medication) cards of narcotics when our local pharmacy made their delivery, by not following our policy. During my investigation, it was determined that there were 898 missing narcotic pills, from nine different facility residents (R7-R15). 145319 Page 4 of 4