Health inspection·February 19, 2026

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that significant medications were administered to residents as indicated by physician orders. This applies to 7 of 7 residents (R8, R9, R10, R11, R12, R13, and R14) who were reviewed for medication administration in a sample of 14.On 02/17/2026 at 3:20 PM, after R8, R9, and R13 complained about receiving their morning medication in the afternoon, this writer asked V18 (Licensed Practical Nurse)-what time she administered medication to residents. V18 said that she was late in administering medications since she came to the facility after 10:00 AM due to some scheduling confusion, and she did not give the scheduled medications until after 11:00 AM and completed around 2:45 PM. V18 said the medications should be given as ordered, within a one-hour window before and after the ordered time.1. On 02/17/2026, at approximately 3:00 PM, R9 said she did not receive any of his insulin, water pill, or inhaler for his breathing conditions. A review of R9's EMR (Electronic Medical Records) showed R8 has diagnoses of diabetes mellitus, asthma, heart disease, and cardiac myopathy. R9's MDS (Minimum Data Set) dated 11/15.2025 showed his cognition was intact.R9's physician's order dated 01/31/2026 showed R9 to receive Humalog Solution 100 UNIT/ML (Insulin Lispro (Human)) 34 units subcutaneously three times a day for diabetes mellitus, 20 units sliding scale with meals subcutaneously with each meal, Insulin Glargine Solution 100 UNIT/ML 70 units subcutaneously every 12 hours for diabetes, order dated 06/13/2025 showed Advair HFA Solution one inhalation two times a day for chronic obstructive pulmonary disease, and the order dated 12/17/2025 showed Furosemide Tablet 40 MG one tablet by mouth two times a day for edema. The Medication Administration Audit report dated 2/17/2026 showed that the 7:30 AM and 9:00 AM ordered scheduled insulin, the 7:30 AM and 11:30 AM ordered sliding scale insulin, and the Advair HFA Solution and furosemide ordered at 9:00 AM, which were administered between 2:36 PM and 2:47 PM.2. On 02/17/2026 at approximately 3:40 PM, R10 was confused and not interviewable. R10's EMR showed R3 had diagnoses of aortic valve insufficiency, hypertensive diseases, bursitis of the left shoulder, facial cellulitis, and anxiety disorder. Physician orders dated 11/02/206 showed Gabapentin Oral Tablet 100 MG twice daily; 12/01/2025, Xanax Oral Tablet 0.25 MG twice daily; 12/07/2025, Amoxicillin-Pot Clavulanate Tablet 875-125 MG twice daily.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered between 12:37 PM and 1:07 PM.3. On 02/17/2026, at approximately 2:30 PM, R11 said she did not receive her morning medication until the afternoon. A review of R11's EMR showed R8 had diagnoses of hallucinations, anxiety, dementia, and MDS dated [DATE], showing R11's cognition was moderately intact. R11's physician's order dated 09/22/2025 showed Haloperidol Oral Tablet 0.5 MG three times a day, Divalproex Sodium Tablet Delayed Release 250 MG three times a day, and Memantine HCl Oral Tablet 10 MG two times a day.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered between 11:07 AM and 11:09 AM.4. On 02/18/2026, at approximately 10:00 AM, V26(Licensed Practical Nurse) said R12 was sent to the Residents Affected - Some Page 1 of 2 145405 145405 02/19/2026 Bria of Westmont 6501 South Cass Westmont, IL 60559

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hospital from the dialysis unit for vomiting and was not available to interview. A review of R12's EMR showed R12 has diagnoses chronic pulmonary disease, end stage renal failure with dependence on dialysis, venous thrombosis and embolism.R12's physician's order dated 11/25/2025 showed Carvedilol 12.5 milligram; the 08/26/2025 order for Advair inhaler 12 hours; and Apixaban 2.5 tablet every 12 hours.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered at 2:57 PM. 5. On 02/17/2026, at approximately 3:10 PM, R13 said she did not get her 9:00 AM medication until 1:30 PM. A review of R12's EMR showed R12 had diagnoses of seizures, atrial fibrillation, hypotension, and chronic pain, and MDS dated 01/2026 showed R12's cognition was intact. R13's physician's order dated 09/21/2025 Apixaban 2.5 milligram every 12 hours for atrial fibrillation, Levetiracetam for seizure 750 by mouth twice a day, dated 11/18/2026, and Lyrica 25 milligram two times a day for pain.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered between 1:13 PM and 1:25 PM.6. On 02/17/2026, at approximately 3:55 PM, R14 said she did not get her 9:00 AM medication until 3:00 PM. A review of R14's EMR showed R14 had been diagnosed with heart failure, fibromyalgia, pulmonary embolism, anxiety disorder, and MDS dated [DATE], which showed R14's cognition was intact. R14's physician's order dated 02/11/2026 showed alprazolam 1 milligram two times a day, gabapentin 300 milligrams three times a day; order dated 10/07/2025: Losartan 50 milligrams for hypertensive heart disease with heart failure. Apixaban 5 mg, 2 times a day.The Medication Administration Audit report dated 2/17/2026 showed that the medications were ordered for 9:00 AM and administered between 3:03 PM and 3:37 PM.7. On 02/17/2026, at approximately 3:10 PM, R8 said she received her medication late. A review of R8's EMR showed diagnoses of chronic kidney disease and chronic obstructive pulmonary disease. R8's physician's order dated 05/04/2024 showed Fluticasone Propionate HFA Aerosol 110 MCG/ACT every 12 hours, and the order dated 02/18/2026 showed Fluticasone Propionate HFA Aerosol 110 MCG/ACT two times a day.The Medication Administration Audit report dated 2/17/2026 showed that R8's medications were ordered for 9:00 AM and administered at 1:45 PM.On 02/18/2026 at 10:31 PM, V2 (Director of Nursing) said the incident was very disappointing and that she was not aware until late in the afternoon that the medications were not administered on time. V2 said the nurses should follow the physician's orders and administer medications one hour before or after the scheduled time.On 02/18/2026 at 2:20 PM, V1(Administrator) said that administering medication too late was unacceptable, and it should not have happened. V1 further stated that it was disappointing and that the nurses should administer medication within a one-hour window before and after, per the physician's order.The facility policy Medication Administration, with a revised date of 11/2025, states, in part, that medication is to be administered at the proper time as ordered. 145405 Page 2 of 2