Health inspection·November 15, 2023

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 transcribe and administer a hospital discharge order for Quetiapine Fumarate for a resident. The facility also failed to ensure a resident had her narcotic available to prevent a resident from experiencing pain. This applies to 2 of 2 residents (R1, R2) reviewed for pharmacy services. The findings include: 1. On 11/9/23 at 12:15 PM, V3 (Family Member) said R1 was hospitalized and discharged back to the facility on [DATE]. V3 said she had reviewed the discharge paperwork from the hospital with V2 (DON) on 10/20/23 and was assured the order for Quetiapine Fumarate 25 mg (Milligrams) was on the discharge paperwork from the hospital. V3 said R1 was hospitalized again at the beginning of November, and she found out from the hospital staff that R1 did not have orders for Quetiapine Fumarate in the transfer paperwork from the facility. V3 said she called the facility and asked the staff about R1's Quetiapine Fumarate, to which they said there were no orders in place. V3 was unable to provide a name for the staff she spoke with. V3 said R1 had not received his Quetiapine Fumarate from 10/19/23 through 11/2/23. V3 said when she asked V2 about it, V2 told her the nurse had not entered the medication orders properly and that was why he did not have his Quetiapine Fumarate reordered. V3 said R1 was admitted to the hospital for behaviors related to not receiving the Quetiapine Fumarate. V3 said prior to his most recent hospitalization, the staff said he was more agitated and restless for the last few weeks. On 11/9/23 at 1:59 PM, V6 (LPN/Licensed Practical Nurse) said R1 needed the Quetiapine Fumarate as it helped him with his behaviors. V6 said since R1 returned from the hospital, he had been really quiet. V6 said when R1 was anxious, he had behaviors such as playing with his stool and smearing it on the nurse's station or spitting. On 11/9/23 at 03:35 PM, V2 said the staff tried to call V3 but did not get a hold of her. V2 said it was her expectation the staff would try more than once to get a hold of V3. V2 said from what she understood, R1 had a dose change and they needed to get a new consent form signed. V2 said if there was no dose change, they would not require a consent form to administer the Quetiapine Fumarate. On 11/14/23 at 10:38 AM, V10 (Nurse Practitioner) said R1 was prescribed Quetiapine Fumarate for sleep and agitation. V10 said she knew R1 had his Quetiapine Fumarate ordered on the discharge summary from the 10/19/23 hospitalization but was made aware later that he was not being administered the medication. V10 said going without the medication could cause R1 to become agitated at night and have difficulty sleeping. V10 also said it was her expectation that if a resident had a medication Page 1 of 5 145582 145582 11/15/2023 Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few order, it should be carried out and if the facility needed to get consent, they should reach out to V3 until they got a hold of her. On 11/14/23 at 10:52 AM, V11 (RN/Registered Nurse) said R1 did have an order for Quetiapine Fumarate from the hospital. V11 said she was the admission nurse and opened the psychotropic medication assessment and imputed the medications into the form and expected the morning shift to follow up to get the consent form signed. V11 said she expected the staff to keep trying to get a hold of V3. V11 said there was a possibility the staff got the consent from V3 but forgot to put the information into the assessment form. On 11/14/23 at 11:43 AM, V12 (Pharmacist) said R1's Quetiapine Fumarate was discontinued on 10/18/23 and restarted on 11/8/23. On 11/14/23 at 12:59 PM, V13 (Consultant Pharmacist) said like any other discharge, the staff would transcribe the orders in the discharge paperwork. V13 said Quetiapine Fumarate was not a controlled drug and if the dose remained the same, they would not need a new consent form to be signed. On 11/14/23 at 01:30 PM, V14 (Psychiatric Mental Health Nurse Practitioner) said she had reduced R1's Quetiapine Fumarate dose from 50 mg to 25 mg on 10/11/23. V14 said she was not made aware R1 had not received his Quetiapine Fumarate for two weeks or that R1 had been sent to the hospital. V14 said she expected the staff to follow the orders given by the hospital. The EMR (Electronic Medical Record) showed R1 was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, acute and chronic respiratory failure, atrial flutter, type 2 diabetes mellitus, dementia with behavioral disturbance, hypertensive heart disease with heart failure, uropathy, anxiety, urinary tract infection, obstructive sleep apnea, anemia, and bipolar disorder. R1's MDS (Minimum Data Set) dated 10/17/23 showed R1 had moderate cognitive impairment. R1's hospital records dated 10/19/23 showed R1 was discharged with an order for Quetiapine Fumarate 25 mg by mouth nightly. R1's October MAR (Medication Administration Review) showed R1 received Quetiapine Fumarate 25 mg from 10/11/23 through 10/16/23 and went to the hospital on [DATE]. R1's October and November MAR does not show R1's Quetiapine Fumarate 25 mg was reordered or administered from 10/19/23 through 11/2/23. R1's POS (Physician Order Sheet) showed an order for Quetiapine Fumarate 25 mg was ordered on 10/11/23 and discontinued on 10/18/23. The next order for Quetiapine Fumarate 25 mg was ordered on 11/7/23. R1's Psychiatric Consult visit form dated 10/11/23 documented the following: Bipolar disorder with anxiety, panic attacks- Lower to Seroquel [Quetiapine Fumarate] 25 mg qhs [every night at bedtime]- spoke with nurse. R1's progress notes document the following: On 10/19/23 at 07:10 PM, a progress note was drafted but not published showing, Tried to call [V3] 145582 Page 2 of 5 145582 11/15/2023 Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565

F 0755 to inform her that [R1] is back from the hospital at 6:10 PM. No answer. Level of Harm - Minimal harm or potential for actual harm On 10/22/23 at 05:35 PM, The client was observed pulling at their [urinary] catheter. Residents Affected - Few On 10/23/23 at 08:33 PM, When resident taken in his room, he put his right hand in his buttocks and pull all stool and throw it across the room, smeared to floor and wall, and wipe his hands in his beddings. On 10/24/23 at 12:23 AM, Patient keeps throwing his nebulizer treatment to the floor. On 10/24/23 at 05:03 AM, Patient picks at his face, forehead and neck, arms until it starts bleeding with his nail. When he gets anxiety, then picks his forehead to bleed. On 10/24/23 at 01:12 PM, Writer placed courtesy visit with [R1] and [V3]. No questions or concerns from [V3]. On 10/24/23 at 02:14 PM, Writer placed courtesy call to [V3]. Writer left voicemail, requested call back. On 10/27/23 at 09:50 PM, Patient put his finger in his rectum and smeared stool all over his bed and sheets. On 10/31/23 at 10:20 AM, Client observed scratching face and picking skin located on their arms. Bleeding notated due to the scratching and picking. On 10/31/23 at 05:30 PM, Writer placed courtesy call with [V3]. [V3] was very thankful and pleased with prompt follow up. On 11/2/23 at 03:22 PM, Writer notified [V3] that [R1] was being sent out to [hospital] due to him 145582 Page 3 of 5 145582 11/15/2023 Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565

F 0755 removing his catheter. Level of Harm - Minimal harm or potential for actual harm The facility's Psychotropic Medications- Use of policy dated 09/2020 showed Residents receiving psychotropic medications will have gradual dose reductions attempted unless clinically contraindicated with appropriate documentation by the MD [Medical Doctor]. The resident and/or resident's responsible party will be notified regarding any changes in medication dosage; this information will be documented in the resident's medical records. Residents Affected - Few 2. On 11/9/23 at 10:05 AM, R2 said she did not get her Norco for two days. R2 said she has neuropathy. R2 said she would get her Norco every four hours and it was two pills. R2 said she was admitted to the facility on [DATE] and only received her prescribed dose of Norco on 11/7/23. R2 said the hospital had not sent the prescriptions for the Norco and the doctor did not sign the order until 11/7/23. R2 said her daughter went to her assisted living facility on 11/5/23 and requested her medication and received four pills. R2 said the facility was giving her Tylenol and that did not address her pain. R2 said when she would ask the facility staff, they would say they were waiting for the order to be approved. R2 said she felt terrible because she had been getting Norco every four hours while in the hospital. On 11/9/23 at 02:24 PM, V4 (Family Member) said the facility put the order in for the Norco on Saturday 11/4/23, but it was not given to her until 11/7/23. V4 said her sister went to the assisted living facility on 11/5/23 and brought four pills. On 11/6/23, V4 said R2 called her and said she had not gotten the Norco. On 11/7/23, V4 said R2 called her again and said she had not received the Norco and were waiting on the order. V4 said apparently R2's primary care physician had not signed off on the medication. V4 said R2 received the four pills spread out over Sunday and Monday when she normally takes six pills a day. V4 said R2 was in a lot of pain because she had severe osteoarthritis in her knees and hips. V4 said R2 had been on Norco for the last five to six years and had been receiving Norco 7.5 mg since August 2023. On 11/9/23 at 03:04 PM, V8 (LPN/Licensed Practical Nurse) said she worked the night R2 was admitted and saw R2 was supposed to receive Norco but told the resident it was not available. V8 said she did not administer any Norco to R2 during the night shift on 11/4/23. On 11/9/23 at 02:38 PM, V7 (Director of Rehab) said R2 told her staff she was in pain and was unable to do therapy, and the staff relayed it to her nurse. V7 said on 11/6/23, the PT (Physical Therapy) evaluation showed R2 had pain with movement and rated it 10 out of 10. On 11/9/23 at 03:19 PM, V9 (PA/Physician Assistant) said she saw R2 on 11/5/23 and was on Norco for pain and chronic opioid dependence. V9 said the facility had never sent over the prescription and she had gotten a call from the nurse requesting the prescription. V9 said they received a prescription on 11/7/23. V9 said usually the resident would receive a Norco prescription as quickly as possible. On 11/9/23 at 03:35 PM, V2 (DON/Director of Nursing) said she expected a script to be filled within a day of receiving. V2 said she saw the script from the doctor on Tuesday morning, and it ended up getting filled in the afternoon on 11/7/23. On 11/14/23 at 10:38 AM, V10 (Nurse Practitioner) said she provided 24-hour's worth of Norco for R2 because she was told the facility staff were unable to reach the primary care physician to get the medication. V10 said she ordered Norco 5-325 mg one tablet, every four hours as needed. V10 said it 145582 Page 4 of 5 145582 11/15/2023 Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565

F 0755 would help the resident but not completely control the pain. Level of Harm - Minimal harm or potential for actual harm On 11/14/23 at 11:43 AM, V12 (Pharmacist) said they got a request for the Norco from the facility on 11/5/23 at 10:40 AM. V12 said they had not received a hard prescription from the provider and reached out to the provider on 11/5/23. V12 said they did not receive a response until 11/6/23. V12 said the order finally arrived on 11/7/23 at 07:45 AM. V12 said the pharmacy gave the facility access to the emergency medication box on 11/6/23, when she received one dose of Norco 5-325 mg at 11:42 AM, 05:11 PM, and then again on 11/7/23 at 12:19 PM. Residents Affected - Few The EMR (Electronic Medical Record) showed R2 was admitted to the facility with acute kidney disease, cervicalgia, atrial fibrillation, heart failure, unsteadiness on feet, limitation of activities due to disability, polyneuropathy, lupus, opioid dependence, and polyosteoarthritis. R2's MDS (Minimum Data Set) dated 11/12/23 showed R2 was cognitively intact. R2's After Visit Summary dated 11/4/23 showed R2 was ordered Norco 7.5-325 mg, two tablets by mouth in the morning, at noon, and at bedtime. The document showed the next dose was due on 11/4/23 at bedtime. The document also showed a second order for Norco 5-325 mg, one tablet every eight hours as needed. R2's November MAR (Medication Administration Review) showed R2 received her first dose of two tablets of Norco 7.5-325 mg on 11/5/23 at 9 PM, and then the next dose of Norco 7.5-325 mg was given on 11/6/23 at 9 PM. It also showed R2 received a dose of Norco 325-5 mg on 11/5/23 at 02:02 PM, and 11/6/23 at 4 PM. R2's progress notes document the following regarding the Norco tablets: On 11/4/23 at 10:12 PM, Norco 7.5-325 mg, give 2 tablets by mouth three times a day for pain with a comment of Waiting on pharmacy to deliver medication. On 11/5/23 at 06:16 AM, it showed Waiting on pharmacy to deliver medication. On 11/5/23 at 09:54 AM, Pharmacy contacted to follow up on pain medication for client. Script not sent to pharmacy. Pharmacy refused access to [emergency med box] for client. Physician notified. DON notified. Care was rendered. On 11/5/23 at 11:11 AM, under the Norco tablet, the comment Tylenol administered was made. On 11/5/23 at 02:02 PM, Norco 5-325 mg, 1 tablet by mouth every eight hours as needed for pain showed the comment: Given two Norco. Client missed 11 AM dosage due to not having the medication. On 11/6/23 at 05:19 AM, Norco 7.5-325 mg, two tablets, showed not available/on order. On 11/6/23 at 10:48 AM, it showed medication not available. Tylenol administered instead for client. On 11/6/23 at 4 PM, Norco 5-325 mg showed medication administered per clients request. The facility's New Admissions Policy dated 06/2022 showed Medications for newly admitted residents are ordered, provided by the pharmacy, and initiated on a timely basis. The facility nurse will verify all admission orders provided with the attending physician before they are submitted to pharmacy or entered into an electronic system, per facility policy. Carry out orders as documented. 145582 Page 5 of 5