Inspection·April 30, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 3. R8's Physician Order Sheet (POS) for April 2025 documents a diagnosis of unspecified lack of coordination, abnormities of gait and mobility, hallucinations, insomnia, repeated falls, Parkinson's disease, other urticaria, hallucinations, mononeuropathy of right upper limb, including shoulder, generalized anxiety, major depression, restless leg syndrome, generalized skin eruption due to drugs and medicaments taken. The April POS also document Gocovri oral capsule extended release 24 hours 137 MG (milligrams) (amantadine HCL (hydrocholoride). Give 1 capsule by mouth at bedtime related to Parkinson disease without dyskinesia, without mention of fluctuations. The POS also documents, R8 has an order for amantadine (generic name for Gocovri). R8's Care Plan with a date initiated of 12/10/2024 document (R8) has Parkinson's disease. Interventions: Give medications as ordered by the Physician. Monitor/document side effects and effectiveness, dated initiated 12/10/2024. R8's Minimum Data Set (MDS) dated [DATE] document she is cognitively intact for decision making of activities of daily living. On 4/29/2025 at 1:11 PM, R11, Husband of R8 stated there were some issues with medications and (R8) did not receive all of her medications something to do with them not being at the Facility. R8's MAR dated April 2024 document R8 did not receive her Gocovri oral capsule extended release 24 hours 137 MG (milligrams) or (Amatadine) for seven out of 28 days, 4/2/2025, 4/20/2025, 4/24/2025, 4/26/2025 and 4/28/2025. R8's Progress Note dated 4/2/2025 at 6:28 PM, Gocovri Oral Capsule extended release 24 hour 137 MG, give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations. Waiting for pharmacy. R8's Progress Note dated 4/20/2025 at 6:00 PM, Gocovri Oral Capsule extended release 24 hour 137 MG give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations. On order. R8's Progress Note dated 4/24/2025 at 11:24 PM, Gocovri Oral Capsule extended release 24 hour 137 MG, give 1 capsule by mouth at bedtime related to Parkinson's; disease without dyskinesia, without mention of fluctuations, waiting on medication for delivery. R8's Progress Note dated 4/26/2025 at 8:04 PM, Gocovri Oral Capsule extended release 24 hour 137 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145454 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145454 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlinville Rehab & Hcc 751 North Oak Street Carlinville, IL 62626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)