Health inspection·September 17, 2025

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. Based on interview and record review, the facility failed to ensure staff documented administration of medications after the medications were administered. This failure affected 1 (R1) resident reviewed for pharmaceutical services in the total sample of 8 residents. Findings include:On 09/15/2025 at 11:49am, R1 stated V3-Licensed Practice Nurse would give his medications late. Occasionally, V3 works the evening shift.R1's admission Record documented R1's diagnoses include but not limited to dementia with mood disturbance, hypertensive heart disease, and adjustment disorder with depressed mood. R1's (06/19/2025) Minimum Data Set documented, Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15., indicating R1's mental status as cognitively intact. R1's 07/2025, 08/2025, and 09/2025 Medication Administration Record indicated V3 worked the evening shift on days 7/10, 7/14, 7/20, 7/21, 7/24, 7/31, 8/5, 8/11, 8/17, 9/14.R1's 07/24/2025 Medication Administration Audit Report Day Shift documented R1's Chlorhexidine Gluconate Solution 0.12 % 2x day, Metoprolol Tartrate Tablet 25 MG 2x a day, Gabapentin Capsule 300 MG 2x a day, Senna S Tablet 8.6-50 MG 2x a day were scheduled at 9am, the administration time was at 11:22am, documented time was at 11:22am and documented by V3 (Licensed Practice Nurse). R1's 08/05/2025 Medication Administration Audit Report Day Shift documented R1's Chlorhexidine Gluconate Solution 0.12 % 2x day, Metoprolol Tartrate Tablet 25 MG 2x a day, Gabapentin Capsule 300 MG 2x a day, Senna S Tablet 8.6-50 MG 2x a day were scheduled at 9am, the administration time was at 12:11pm, documented time was at 12:12pm and documented by V3 (Licensed Practice Nurse). R1's 08/11/2025 Medication Administration Audit Report Day Shift documented R1's Chlorhexidine Gluconate Solution 0.12 % 2x day, Metoprolol Tartrate Tablet 25 MG 2x a day, Gabapentin Capsule 300 MG 2x a day, Senna S Tablet 8.6-50 MG 2x a day were scheduled at 9am, the administration time was at 10:35am, documented time was at 10:36am and documented by V3 (Licensed Practice Nurse). R1's 7/10/2025 Medication Administration Audit report Evening shift documented R1's Chlorhexidine Gluconate 2x daily, Gabapentin 300mg 2x daily, Metoprolol Tartrate Tablet 25 MG 2x daily, Senna S Tablet 8.6-50 MG 2x daily, Protonix Tablet Delayed Release 40 MG every 12 hours, Anucort-HC Rectal Suppository 25 MG every 12 hours were scheduled at 6pm; and the administration time and documented time were at 9:51pm and documented by V3 (Licensed Practice Nurse). R1's 07/14/2025 Medication Administration Audit Evening shift documented tR1's Chlorhexidine Gluconate 2x daily, Gabapentin 300mg 2x daily, Metoprolol Tartrate Tablet 25 MG 2x daily, Senna S Tablet 8.6-50 MG 2x daily, Protonix Tablet Delayed Release 40 MG every 12 hours, Anucort-HC Rectal Suppository 25 MG every 12 hours were scheduled at 6pm;; the administration time was at 10:04pm, documented time was at 10:06pm and documented by V3 (Licensed Practice Nurse). R1's 07/20/2025 Medication Administration Audit report Evening shift documented R1's Chlorhexidine Gluconate 2x daily, Gabapentin 300mg 2x daily, Metoprolol Tartrate Tablet 25 MG 2x daily, Senna S Tablet 8.6-50 MG 2x daily, Protonix Tablet Delayed Release 40 MG every 12 hours were scheduled at 6pm; and the administration time was at 9:01pm, documented time was at 21:03pm and documented by V3 (Licensed Practice Page 1 of 2 145484 145484 09/17/2025 Elevate Care Chicago North 2451 West Touhy Avenue Chicago, IL 60645

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nurse). R1's 08/11/2025 Medication Administration Audit report Evening shift documented that R1's Chlorhexidine Gluconate 2x daily, Gabapentin 300mg 2x daily, Metoprolol Tartrate Tablet 25 MG 2x daily, Senna S Tablet 8.6-50 MG 2x daily, Protonix Tablet Delayed Release 40 MG every 12 hours, Anucort-HC Rectal Suppository 25 MG every 12 hours were scheduled at 6pm; and the administration time was at 9:57pm, documented time was at 9:57pm and documented by V3 (Licensed Practice Nurse). On 09/17/2025 at 12:09pm, V3 (Licensed Practice Nurse) stated some residents have scheduled 6pm medications and 9pm medications during the evening shift. If the schedule is at 6pm, she administers the medication between 5pm and 7pm; and if the schedule is at 9pm, she administers the medication between 8pm and 10pm. V3 stated she is supposed to sign the eMAR (electronic Medication Administration Record) right after she gave the medications to acknowledge or document she gave the medications; she is not supposed to wait in documenting medication administration. V3 stated it is possible she opened the eMAR at 6pm, gave the medications to him (R1), and signed or acknowledged she gave the medications later during the 9pm medication pass. V3 stated she is expected to sign the eMAR right after the medications were administered. On 09/17/2025 at 12:21pm, V2 stated nurses are expected to sign or acknowledge the medications are administered right after the nurse gave the medications. Nurses are not expected to wait 3 hours or so to document they administered the medications. The purpose is to make sure the medications are administered timely. The 10/25/2024)Administration Procedures for All Medications documented, Policy. To administer medications in a safe and effective manner. Procedures: J. After administration, return to cart, and document administration in the MAR. 145484 Page 2 of 2