Health inspection·November 18, 2025

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to follow physician orders to ensure as needed pain medication (oxycodone) was administered to one resident as prescribed. This affected one of three residents (R1) reviewed for pain management. This failure resulted in R1 being admitted to this facility on 9/24/25 and requested narcotic pain medication, rated pain as 6 out of 10, but was informed by nurse R1's medication was not available until the next morning.Findings include:On 9/30/25 at 10:55 AM, R1 stated that R1 was admitted to this facility on Wednesday, 9/24/25. R1 stated that she asked for oxycodone (pain medication) and was informed that her medications had not been delivered yet. R1 stated that R1's oxycodone was delivered (on 9/25/25), and she received a dose around 9:00 AM.On 9/30/25 at 1:50 PM, V2 DON (director of nursing) stated that the nurse is expected to sign out medications on the controlled substance sheet and MAR (medication administration record) when a narcotic (oxycodone) is being administered. V2 stated that the medications are to be removed at time of administration. V2 stated that if the hospital sends a prescription for narcotic medication with the resident upon admission, the nurse can call the pharmacy to get emergency authorization, fax the prescription to the pharmacy, and obtain an authorization code to get into the facility's convenience box to remove medication. V2 stated that the nurse has to get an authorization code every time the nurse wants to give a controlled substance until that medication is delivered. V2 stated that the pharmacy delivers medications to the facility twice daily, once in the morning and once in the afternoon.11/14/25 at 1:38 PM, V13 (pharmacist) stated that 29 tablets of oxycodone were delivered to the facility for R1 on 9/25/25 at 7:00 AM. V13 stated that no access codes were given to any nurse for oxycodone on 9/24 or 9/25.On 11/14/25 at 4:54 PM, V11 RN (agency registered nurse) stated that V11 worked 9/24/25 3:00 PM-11:00 PM and was assigned to provide care for R1. V11 stated that R1 requested a dose of oxycodone for pain 6 out of 10. V11 stated that V11 informed R1 that R1's oxycodone (narcotic) medication was not available and offered R1 acetaminophen instead. V11 stated that V11 did not access the convenience box to see if oxycodone was available to administer to R1.On 11/17/25 at 1:46 PM, V12 NP (nurse practitioner) stated that the nurse is expected to assess the resident for pain every shift and when pain medication is requested. V12 stated that nurse is expected to reassess the resident's pain level post medication administration for its effectiveness. V12 stated that the nurse is expected to check the facility's convenience box for the narcotic medication if the medication has not been delivered yet. V12 stated that the nurse is expected to notify the physician if the pain medication is not available and request an alternative medication. R1's medical record notes the following:9/24/25 at 1:13 PM, R1 admitted to the facility. R1 denies pain.9/24 at 10:02 PM, V11 RN noted as needed pain medication (oxycodone) is not available at this time. R1 refused acetaminophen for pain stating it causes gastrointestinal discomfort.9/25 at 9:00 AM, one tablet of oxycodone was signed out on R1's controlled substance sheet. Administration was not documented in R1's MAR (medication administration record).The controlled drug administration record notes oxycodone 5mg tablets 1-2 Residents Affected - Few Page 1 of 2 145363 145363 11/18/2025 Warren Barr Oak Lawn 9401 South Kostner Avenue Oak Lawn, IL 60453

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tablets every three hours as needed for pain control. 29 tablets of oxycodone were received in the facility on 9/25/25 at 7:00 AM. It also notes that the first dose of oxycodone was signed out 9/25 at 9:00 AM. R1's MAR, dated September 2025, notes the first dose of oxycodone was administered on 9/25/25 at 4:04 PM.V12 NP initial visit, dated 9/25/25, notes R1 status post right hip arthroplasty on 9/19/25. R1 noted pain with movement of leg. Pain management with oxycodone. R1's pain care plan, initiated 9/25/25, notes R1 has pain related to status post hip surgery. Interventions identified include but not limited to R1 will report to the nurse complaints of any pain or requests for pain treatment; R1 would like the nurse to review and monitor R1's pain level.R1's hospital medical records, dated 9/24/25, notes a prescription for oxycodone 5mg tablets, take 1-2 tablets by mouth every three hours as needed. Indication: acute post operative pain.The facility's pain policy, revised7/29/25, notes if available in the convenience box, the pain medication ordered will be administered. After the administration of as needed pain medication, the resident will be reassessed for the effectiveness of the pain medication. 145363 Page 2 of 2