Health inspection·November 18, 2025

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 interview and record review the Facility failed to ensure medication errors did not occur for 1 of 3 residents (R6) reviewed for medication errors in the sample of 9. Findings include: R6's Physician Order Sheets (POS) for August 2025 documents a diagnosis of unspecified convulsions. The POS does not include a diagnosis of seizures or epilepsy. R6 has an order for carbamazepine ER (extended release) oral tablet 400 milligrams (mg) give 1 tablet by mouth two times a day for seizures, and phenytoin sodium extended capsule 100 mg, give 2 capsules by mouth two times a day for seizures, and 750 mg of methocarbamol, 1 tablet three times a day for muscle spasms. R6's Minimum Data Set (MDS) dated [DATE] document R6 was cognitively intact for decision making of activities of daily living and he was documented as having Seizure disorder or epilepsy. R6's Care Plan with a created date of 5/30/2025 documents R6 hasseizure activities. Interventions Give medications as ordered. Monitor/document for effectiveness and side effects. On 11/17/2025at 9:14 AM, R6 stated, I have been taking seizure medication almost all of my life. There were some issues with the nurse that day getting to the facility, and my seizure medication was 2 1/2 hours late, and it caused me to have a seizure, and the next day I got sent out to the hospital because I was having a seizure. It's important I do not get my medication late. On 11/17/2025 at 10:30 AM, R5 (Wife) and roommate of R6 stated (R6) has had seizures his whole life. As long as he takes his medication on time, we don't have any issues. Way back in August when he went out to the hospital, the (facility) was short a nurse and when the nurse was coming from (different town) and she was helping out, but she did not really work here. Once she got here, she was late giving him his seizure medication by almost two and half hours. I talked with (V1) about it, and we talked about how (R6) should always get his seizure medications on time. R6's August MAR document on 8/27/2025 methocarbamol was scheduled to be given at 8:00 AM but was not given until 10:25 AM. R6's carbamazepine was scheduled to be given at 8:00 AM but was not given until 10:24 AM, and the phenytoin sodium was scheduled to be given at 8:00 AM and was not given until 10:25 AM. R6's three medications related to muscle spasms and seizures were given late. R6's Health Status Note dated 8/28/2025 at 9:00AM, Note Text: Resident noted to have small seizure activity. A&O (alert and orientated) in between activity. Resident requested to go to ER (emergency room) for evaluation. This nurse placed called to (V19 Medical Doctor) and received order to send to (hospital) for evaluation. EMS (emergency medical services) called. The Author of this note was V9 (Licensed Practical Nurse/LPN). R6's ED (Emergency Department) Notes dated 8/28/2025 at 9:46 AM, Chief complaint from Nursing triage note: Chief complaint from (Facility) sent due to seizures lasting less than 10 seconds. EMS reports meds were given late. Hx (history of) seizures. R6's Health Status Note dated 8/28/2025 at 12:02 PM, Note Text: Received call from ER department reporting labs came back normal. CT done and came back normal. No seizure activity noted. 1000 mg Keppra given. Resident being discharged back to facility. R6's discharge papers dated 8/28/2025 Seizure disorder.R6's Grievance form dated 10/25/2024, Hates he has seizures if his medication is Residents Affected - Few Page 1 of 2 145497 145497 11/18/2025 Three Springs Sr Living & Rhab 161 Three Springs Road Chester, IL 62233

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few even a minute late and is concerned that he is not getting meds at exactly at 8 AM and 8 PM. On 11/17/2025 at 12:32 PM, V19 (Medical Doctor) stated (R6) has had the seizure/epilepsy diagnosis for years. It is important that his orders are being followed, and if (R6) did not receive his medication on time or as ordered it could cause (R6) to have seizures/harm and would not be good to miss or have delayed medications. On 11/18/2025 at 9:57 AM, V22 (Pharmacist) stated normally as long as they have a prescription for the medicine and for (R6) convulsion would fit the bill for a diagnosis for those medications. They do not have a diagnosis for seizures and or epilepsy for (R6). Taking medications late for seizures may or could contribute to a seizure. It would depend on if a seizure occurred as to whether it would be a significant medication error. If a seizure occurred, then yes. On 11/18/2025 at 10:07 AM, V18 (LPN) stated, I know that day I got a call from the (Facility) because they were down a nurse. It was about an hour a drive to the facility by the time I got there and started passing out medications the medications were late. Unfortunately, I did not notify the physician and let him know my medications were late. A lot of the medications were late being passed out that day I did the best I could do under the circumstances. On 11/18/2025 at 12:45 PM, V9 (LPN) stated I know (R6's) wife told me that he had been having some seizure activities and the day before he had gotten his seizure medication late. They are very particular about his seizure medication. When I saw (R6) he was experiencing small twitches movements, so I sent him out. The Facility Medical Policy with a revision date of 2012 documents, Medications shall be administered in a safe and timely manner, and as prescribed. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose. 145497 Page 2 of 2