Health inspection·July 17, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to supervise a resident during medication administration to ensure the resident ingested the medications and did not store them in his room. This applies to 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4. The findings include: R1's Medication Administration Record shows R1 receives the following medications at 12:00PM: Senna 8.6mg (Stool softener), Metoprolol 25mg (Antihypertensive), Tab-a-vite 1 tab (Vitamin Supplement), Preservision 2 soft gels (Supplement), Lisinopril 10mg (antihypertensive), Claritin 10mg (Allergy), Gabapentin 100mg (2) (Nerve Pain) and Norco 10-325mg 1 tab. On 7/17/24 at 10:50AM, R1 was seated in his wheelchair in his room. Surveyor and R1 discussed his concerns about the facility. The conversation was very disjointed and hard to follow but R1 stated, This facility does not monitor controlled medication and I find medications all over the place. All over my bed. R1 then reached for a stack of cups on his over bed table, removed several cups from the top of the stack and showed Surveyor several pills in the bottom of a cup. (8 oval shaped, white pills) Surveyor asked R1 what the pills were and R1 stated, Norco (Schedule II Narcotic Analgesic). Surveyor stated to R1 he could not store the pills in his room and they would have to be removed by the V1(Administrator) or V2 (Director of Nursing). R1 stated, I am fine with that. Surveyor attempted to question R1 about how he got them, and R1 continued to insist he finds them in his bed. R1 stated he always takes his medications when they are given to him, but then he finds those in his bed because the facility is not accountable for their medications and he feels there is a whole drug operation going on within the facility and no one gives a d***. On 7/17/24 at 11:45 AM, V3 (Licensed Practical Nurse/LPN) stated, I take him all his meds and hand them to him- He takes pictures of them and then opens them and lays them on the bed. He always says , 'I will take them why are you standing there?' and he will not allow me to stand there and watch him. I have to give him his medications at 12:00PM on the dot. On 7/17/24 at 12:00PM, V3 took a strip of R1's medications (7 medications) and 1 medication card (Norco) into R1's room. R1 took the card, laid it on the bed, took a picture of the front of the card, then turned it over and took a picture of the back of the card. R1 stated, I take a picture and it goes right to (University Hospital) for verification that it is okay for me to take. R1 then confirmed which medication he should pop out of the card, and V3 verified it was the correct pill. R1 popped the Norco into his hand, took the water from V3 and swallowed the medication. V3 then left the strip of unopened medications on the bed as resident began taking pictures of the medications. Page 1 of 2 145563 145563 07/17/2024 The Citadel at Saint Anne Place 4405 Highcrest Road Rockford, IL 61107

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V3 and Surveyor left the room and V3 stated, I am shocked. That is the first time he has even done that and taken the medication in front of me. I am so shocked. He has NEVER done that before. The facility policy entitled Controlled Substances, dated 6/2024, states, Controlled substances must be stored in the locked medication room or medication cart in a locked container, separate from containers for any non-controlled medications. The container must remain locked at all times, except when it is accessed to obtain medications for residents. The facility policy entitled Administering Medications, dated 12/2021, states, Residents may self administer their own medications only if the attending physician, in conjunction with the nurse assessment, has determined that they have the capacity to do so safely. 145563 Page 2 of 2