Health inspection·March 4, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medications were obtained in a timely manner to prevent residents from missing medication doses as ordered by the physician. This applies to 2 of 3 residents (R1 and R2) reviewed for improper nursing care in the area of missing medication doses in the sample of 3. The findings include: 1. The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including respiratory failure, pneumonia due to coronavirus disease, type 2 diabetes, and hypertension. R1's February 2025 MAR (Medication Administration Record) showed R1 was to receive Magnesium Chloride-Calcium Carbonate oral tablet delayed release 71.5-119 mg (milligrams), one tablet by mouth in the morning for supplement. The MAR continued to show R1 did not receive the medication on February 19, February 20, or February 21, 2025. The EMR showed the following documentation for R1 regarding missing medications: On February 19, 2025, at 10:32 AM, V8 (RN/Registered Nurse) documented, [Magnesium Chloride-Calcium Carbonate] oral tablet delayed release 71.5-119 mg (milligrams), give one tablet by mouth in the morning for supplement. N/A (Not Available). On February 20, 2025, at 9:22 AM, V7 (RN) documented, [Magnesium Chloride-Calcium Carbonate] oral tablet delayed release 71.5-119 mg (milligrams), give one tablet by mouth in the morning for supplement. Unavailable. On February 21, 2025, at 9:30 AM, V6 (RN) documented, [Magnesium Chloride-Calcium Carbonate] oral tablet delayed release 71.5-119 mg (milligrams), give one tablet by mouth in the morning for supplement. Requested medication from family. On March 3, 2025, at 2:37 PM, V2 (DON/Director of Nursing) said it is the facility's responsibility to obtain a resident's prescribed medications, either from the pharmacy or the facility will obtain the medication. V2 continued to say it was not the family's responsibility to obtain R1's missing medication. Page 1 of 2 145522 145522 03/04/2025 Beacon Hill 2400 South Finley Road Lombard, IL 60148

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. The EMR showed R2 was admitted to the facility on [DATE], with multiple diagnoses including sepsis, pneumonia, chronic kidney disease, spinal stenosis, hypertension, and left knee replacement. R2's February 2025 MAR showed R2 was to receive Calcium-Vitamin D tablet 600-200 mg-unit, give one tablet two times a day for supplement. The MAR continued to show R2 did not receive the medication on February 17 and February 18, 2025. The EMR showed the following documentation for R2 regarding missing medication: On February 17, 2025, at 9:18 AM, V6 (RN) documented, Calcium-Vitamin D tablet 600-200 mg-unit, give one tablet two times a day for supplement. Not available. On February 17, 2025, at 4:23 PM, V9 (Nurse) documented Calcium-Vitamin D tablet 600-200 mg-unit, give one tablet two times a day for supplement. Waiting for delivery. On February 18, 2025, at 9:36 AM, V6 (RN) documented R2's Calcium-Vitamin D tablet 600-200 mg-unit, was not given. On February 18, 2025, at 5:29 PM, V10 (RN) documented, Calcium-Vitamin D tablet 600-200 mg-unit, give one tablet two times a day for supplement. Awaiting for house supply. On March 3, 2025, at 2:36 PM, V2 said R2's calcium-vitamin D order was changed to a medication we had in stock. V2 said the order change should have happened sooner so R2 did not miss any doses of his medication. 145522 Page 2 of 2