Health inspection·April 24, 2024

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 from the pharmacy in a timely manner to prevent residents from missing medication doses as ordered by the physician. This applies to 3 of 4 residents (R1, R2, and R4) reviewed for improper nursing care in the area of missing medication doses in the sample of 4. The findings include: 1. On April 22, 2024 at 2:20 PM, R1 said, I missed my morning dose of insulin (Humulin R U-500) on April 19, 2024. The evening of April 18, they ran out of the insulin and did not have enough to give me a full dose. On April 19, I was supposed to get a second dose at 2:00 PM and they still did not have the insulin in stock. It finally came at 3:00 PM that day. This happens every month. My blood sugars are all over the place and I should not be missing doses. They also ran out of my Vitamin D that I take once a month, and my depression medication. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, open wound of the right buttock, diabetes, generalized anxiety disorder, chronic kidney disease, encounter for change or removal of surgical wound dressing, localized edema, PVD (Peripheral Vascular Disease) elevated liver enzymes, fatty liver, depressive episodes, psoriasis, acquired absence of left leg below the knee, and iron deficiency anemia. R1's MDS (Minimum Data Set) dated February 14, 2024 shows R1 is cognitively intact, is independent with oral hygiene and toilet hygiene, requires set up assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of urine, and occasionally incontinent of stool. The EMR shows the following documentation for R1 regarding missing medications: On January 1, 2024 at 10:11 PM, V7 (RN-Registered Nurse) documented, Humulin R U-500 (Insulin) Inject 220 units subcutaneously three times a day. On order. (On order means medication was not available). On January 26, 2024 at 11:42 AM, V8 (RN) documented, Ozempic (diabetes medication) Inject 2 mg. subcutaneously one time a day every Friday related to Type 2 diabetes. On order. On February 13, 2024 at 3:15 PM, V8 (RN) documented, Humulin R U-500 Inject 220 units Page 1 of 6 145582 145582 04/24/2024 Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565

F 0755 subcutaneously three times a day. On order. Level of Harm - Minimal harm or potential for actual harm On February 13, 2024 at 9:40 PM, V9 (Agency Nurse) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day On order. Residents Affected - Few On February 14, 2024 at 8:43 AM, V8 (RN) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day. On order. On April 5, 2024 at 8:39 AM, V8 (RN) documented, Ozempic Inject 2 mg. subcutaneously one time a day every Friday related to Type 2 diabetes. On order. On April 6, 2024 at 1:50 PM, V13 (LPN-Licensed Practical Nurse) documented, Ergocalciferol Capsule (Vitamin D) 50,000 units, give one capsule by mouth one time a day starting on the 6th and ending on the 6th evening. On order. On April 13, 2024 at 8:25 AM, V8 (RN) documented, Duloxetine HCl (Hydrogen Chloride) oral capsule delayed release particles 30 mg. (milligrams) give 1 capsule by mouth one time a day for MDD (Major Depressive Disorder) total dose 90 mg. daily please give with 60 mg. cap. On order. On April 19, 2024 at 8:36 AM, V11 (RN) documented, Humulin R U-500 (Insulin) Inject 220 units subcutaneously three times a day. On order. 2. The EMR shows R2 was admitted on [DATE] with multiple diagnoses including, hemiplegia and hemiparesis following cerebral infarction, COPD (Chronic Obstructive Pulmonary Disease), diabetes with foot ulcer, morbid obesity, chronic kidney disease, left shoulder rotator cuff tear, adjustment disorder with depressed mood, sleep apnea, PVD (Peripheral Vascular Disease), aphasia, long-term use of insulin, and heart disease. R2's MDS dated [DATE] shows R2 is cognitively intact and requires supervision with all ADLs. R2 is occasionally incontinent of urine, and always continent of stool. The EMR shows the following documentation for R2: On January 25, 2024 at 6:54 PM, V8 (RN) documented, Insulin NPH (Human) (Isophane) Subcutaneous Suspension, inject 76 units subcutaneously two times a day related to Type 2 diabetes. On order. On March 18, 2024, V9 (Agency Nurse) documented, Ozempic Inject 0.5 mg. subcutaneously one time a day every Monday related to Type 2 diabetes. Drug on order. On March 28, 2024, V9 (Agency Nurse) documented, Lidocaine Pain Relief External Patch 4 percent, apply to left shoulder topically in the morning for pain and remove per schedule. On order. On April 3, 2024 at 6:23 Am, V7 (RN) documented, Lidocaine Pain Relief External Patch 4 percent, apply to left shoulder topically in the morning for pain and remove per schedule. On order. On April 12, 2024 at 5:46 AM, V7 (RN) documented, Lidocaine Pain Relief External Patch 4 percent, apply to left shoulder topically in the morning for pain and remove per schedule. On order. On April 21, 2024 at 6:19 AM, V7 (RN) documented, Lidocaine Pain Relief External Patch 4 percent, 145582 Page 2 of 6 145582 04/24/2024 Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565

F 0755 apply to left shoulder topically in the morning for pain and remove per schedule. On order. Level of Harm - Minimal harm or potential for actual harm 3. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including, end-stage renal disease, palliative care chronic kidney disease, Type 2 diabetes with hyperglycemia, cerebral infarction affecting the right, dominant side, vascular dementia, heart failure, presence of cardiac pacemaker, and dependence on renal dialysis. Residents Affected - Few On April 13, 2024 at 6:25 AM, V7 (RN) documented, Lidocaine External Patch 4 percent, apply to right foot topically in the morning for pain management. On for 12 hours and off for 12 hours and remove per schedule. On order On April 23, 2024 at 1:21 PM, V6 (Pharmacy Order Entry Clerk) said, The facility is supposed to request refills through their electronic charting system or via FAX. They can also call us for a STAT refill request if they did not follow the process. We provide two medication deliveries to the facility each day. I do the order entry for orders that are received. Someone is here 24 hours a day to enter orders. For [R1], we received a call to have the Humulin R U-500 refilled on April 19, 2024 at 4:06 AM. The insulin was sent to the facility on April 19, 2024 at 3:06 PM. April 2, 2024 was the last time the insulin was sent to the facility, which was enough insulin to take [R1] through April 11, 2024. The Ozempic was requested on April 5, 2024 at 8:00 AM and we sent it on April 5, 2024 at 1:39 PM. For [R2's] Lidocaine patches, the facility requested a refill on April 21, 2024 and we sent the patches on April 22, 2024 at 4:00 AM. [R2's] Ozempic and insulin refills were called in on the same day they were sent to the facility. On April 23, 2024 at 2:19 PM, V5 (NP-Nurse Practitioner) said, The nurses are supposed to be calling pharmacy to get the medications. The assumption by myself and the physician is the patients are getting the medications we order. On April 23, 2024 at 2:50 PM, V2 (DON-Director of Nursing) said facility staff need to request medication refills four or five days ahead of time so residents do not run out of medications. The facility's policy entitled, Reordering Medications (Facilities Ordering Refills on Demand) dated, 2005-2021 shows: Policy/Purpose: Medications are reordered in advance so as not to have lapses in therapy. Procedure: 1. The nursing staff is responsible for reordering medications. 2. Medications should be reordered when, in the judgment of the nurse, a 2-day supply of medication remains. 3. Reorders should be submitted either by: a. Using the re-order function in the facility's eMAR (Electronic Medication Administration Record) system (only if there is a pharmacy interface), or b. Removing the barcode label, affixing it to the reorder sheet, and faxing it - in a fax document carrier - to the pharmacy. 145582 Page 3 of 6 145582 04/24/2024 Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer Insulin as ordered by the physician. The failure resulted in R1 having elevated blood sugars and elevated lab values. This applies to 2 of 4 residents (R1, R2) reviewed for improper nursing care in the area of missing medication doses in the sample of 4. Residents Affected - Few The findings include: 1). On April 22, 2024 at 2:20 PM, R1 said, I missed my morning dose of insulin (Humulin R U-500) on April 19, 2024. The evening of April 18, they ran out of the insulin and did not have enough to give me a full dose. On April 19, I was supposed to get a second dose at 2:00 PM and they still did not have the insulin in stock. It finally came at 3:00 PM that day. This happens every month. My blood sugars are all over the place and I should not be missing doses. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, open wound of the right buttock, diabetes, generalized anxiety disorder, chronic kidney disease, encounter for change or removal of surgical wound dressing, localized edema, PVD (Peripheral Vascular Disease) elevated liver enzymes, fatty liver, depressive episodes, psoriasis, acquired absence of left leg below the knee, and iron deficiency anemia. R1's MDS (Minimum Data Set) dated February 14, 2024 shows R1 is cognitively intact, is independent with oral hygiene and toilet hygiene, requires set up assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of urine, and occasionally incontinent of stool. R1's EMAR (Electronic Medication Administration Record) dated April 2024 shows the following physician's orders: - Humalog (Insulin Lispro) 100 units/ml (units per milliliter) inject 24 units SQ (subcutaneously) at 8:00 AM, 28 units at 12 noon, and 32 units at 5:00 PM. This was ordered on dated 10/11/2023. - Humulin R U-500 (500 units/ml) inject 220 units at 8:00 AM, 2:00 PM, and 8:00 PM. This was ordered on 11/21/2023. - Humalog (Insulin Lispro) 100 units/ml inject as per the sliding scale for blood glucose level 150 to 450 mg/dL (milligram per deciliter). This was ordered on 3/4/2024. R1's EMAR dated April 2024 also shows R1 has physician's order to administer Jardiance 25 mg one tablet daily at 9:00 AM and Ozempic 2 mg SQ every Friday for Type 2 Diabetes Mellitus. The EMR shows the following documentation for R1 regarding missing medications: On January 1, 2024 at 10:11 PM, V7 (RN-Registered Nurse) documented, Humulin R U-500 (Insulin) Inject 220 units subcutaneously three times a day. On order. (On Order means the medication was not available). The facility does not have documentation to show what R1's blood sugar level was on January 1, 2024 at 10:00 PM. The facility does not have documentation to show R1's physician was notified the medication was not administered as ordered. 145582 Page 4 of 6 145582 04/24/2024 Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565

F 0760 The EMR shows R1's next blood sugar reading was obtained on January 2, 2024 at 8:00 AM. R1's blood sugar level was 363 (mg/dL milligrams/deciliter). Level of Harm - Actual harm Residents Affected - Few On February 13, 2024 at 3:15 PM, V8 (RN) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day. On order. The EMR shows R1's blood sugar level was 248. Nursing documentation shows R1 was given 165 of the 220 units ordered. The facility does not have documentation to show R1's physician was notified the medication was not administered as ordered. On February 13, 2024 at 9:40 PM, V9 (Agency Nurse) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day. On order. The facility does not have documentation to show R1's physician was notified the medication was not administered as ordered. On February 14, 2024 at 8:43 AM, V8 (RN) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day. On order. The EMR shows R1's blood sugar level was 282. The EMR continues to show R1's blood sugar level was 384 at 2:00 PM. On April 19, 2024 at 8:36 AM, V11 (RN) documented, Humulin R U-500 (Insulin) Inject 220 units subcutaneously three times a day. On order. The facility does not have documentation to show R1's physician was notified the medication was not administered as ordered. The EMR shows the following blood sugar readings for R1 on April 19, 2024: 301 at 8:00 AM, 296 at 12:00 PM, 296 at 2:00 PM, and 315 at 8:00 PM. HBA1C (GlycoHemoglobin) laboratory results show a patient with diabetes has glycemic control of their diabetes if they have a reading of less than 7 percent. R1's HBA1C results for the period January 10, 2024 to April 10, 2024 show: January 10, 2024 - 8.3 percent February 12, 2024 - 7.7 percent February 19, 2024 - 7.7 percent March 11, 2024 - 9.3 percent April 10, 2024 - 9.6 percent On April 23, 2024 at 2:19 PM, V5 (NP-Nurse Practitioner) said, [R1] is a brittle diabetic. She has high blood sugars and receives almost 700 units of insulin a day. When she misses insulin doses, her blood sugars are higher. It is a lot for her to miss even one dose of insulin. We do HBA1C labs to check the control of her diabetes. This gives us a picture of her blood sugar control over the past three months. If that number is high or is going up, then her diabetes is not under control. The nurses are supposed to be calling the pharmacy to get the medications. She should be getting her medications. The assumption by myself and the physician is the patients are getting their medications. 2). The EMR shows R2 was admitted on [DATE] with multiple diagnoses including, hemiplegia and hemiparesis following cerebral infarction, COPD (Chronic Obstructive Pulmonary Disease), diabetes with foot ulcer, morbid obesity, chronic kidney disease, left shoulder rotator cuff tear, adjustment disorder with depressed mood, sleep apnea, PVD (Peripheral Vascular Disease), aphasia, long-term use of 145582 Page 5 of 6 145582 04/24/2024 Alden Estates of Naperville 1525 South Oxford Lane Naperville, IL 60565

F 0760 insulin, and heart disease. Level of Harm - Actual harm R2's MDS dated [DATE] shows R2 is cognitively intact and requires supervision with all ADLs. R2 is occasionally incontinent of urine, and always continent of stool. Residents Affected - Few The EMR shows the following documentation for R2: On January 25, 2024 at 6:54 PM, V8 (RN) documented, Insulin NPH (Human) (Isophane) Subcutaneous Suspension, inject 76 units subcutaneously two times a day related to Type 2 diabetes. On order. The facility's policy entitled Medication Administration: General Guidelines dated 03/2021 shows: C. Policy: All medications shall be administered as prescribed by personnel authorized to do so in accordance with standard practice and current regulations . D. Procedure: .6. If the physician's medication order cannot be followed, the physician should be notified, depending upon the situation . 145582 Page 6 of 6