Inspection·September 27, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the Facility failed to properly store and label medications and dispose of expired medications for 4 of 4 residents (R25, R59, R63, R283) reviewed for medication storage and labeling in the sample of 46. Findings include: On 9/26/24 at 9:15 AM, the medication cart on the B Hall was inspected with V12, Registered Nurse (RN). The medication cart contained the following: 1-R63's Humalog Quickpen labeled 8/24 in black marker. V12, RN, stated insulin pens are dated upon opening and are usually thrown out after 30 days. 2-R63's unopened vial of Epogen with packing instructions documenting, Refrigerate. 3-One half of a white circular tab in a medicine cup that was not labeled or dated. V12, RN, stated, That is magnesium for R59. She gets half a tab in the morning and the other half in the afternoon. 4- One opened carton of thickened lemon water labeled 5/20 in black marker. V12, RN, stated that will be thrown away. On 9/26/24 at 9:22 AM, the medication cart on the F hall was inspected with V10, RN. The medication cart contained the following: 5-R25's sealed, unopened Latanoprost Opthalmic Solution 0.005% eye drops with the packing instructions, Refrigerate Unopened. 6-R25's Tresiba FlexTouch Solution Pen-Injector 100 unit/milliliter dated 8/24/24 in black marker. 7-One opened Humalog pen dated 8/1/24 in black marker that was not labeled with any resident's name. 8-One opened Novolog Kwikpen dated 3/14/24 in black marker that was not labeled with any resident's name. V10, RN, stated she does not know who the insulin pens belong to, because night shift gives the morning insulin. (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 6 Event ID: 145508 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 145508 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Highland Health Care Center 1450 26th Street Highland, IL 62249 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)