Inspection·October 11, 2024

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 ensure 2 of 3 (R2, R4) residents reviewed for viral infections in the sample of 3 were administered the correct dose of antiviral medications. This failure resulted in R2 being hospitalized for 21 days and R4 having significant side effects. Residents Affected - Few The findings include: 1. On 10/11/24 at 12:10 PM, V6, Nurse Practitioner (NP), said R2 was diagnosed with shingles and was put on Valtrex (an antiviral), 1 gram (1000 milligrams) three times a day for seven days, which is a standard dose for shingles. V6 said R2 dose should have been adjusted because he is a dialysis patient. R2's dose should have been 500 milligrams (mg) three times a day for seven days. V6 said she does not know why it was not adjusted; it just did not get adjusted. V6 said signs and symptoms of a Valtrex overdose would include confusion and delirium. V6 said R2 was sent to the hospital for low blood glucose but admits that part of it could have been that he had extra Valtrex in his system. V6 said patients with renal (kidney) problems should be given doses of antiviral medications (like Valtrex) based on their creatinine clearance (labs indicating kidney function). On 10/11/24 at 2:25 PM, V2, Director of Nursing, said R2 was admitted to the hospital (on 9/14/24) with altered mental status. V2 said R2 had been receiving Valtrex. V2 said it is his understanding that the NP put in an order for regular dosing versus renal dosing, and R2 was dependent on renal dialysis. V2 said the Valtrex dosing contributed to R2's hospitalization as there are precautions for Valtrex affecting renally impaired patients. V2 said signs and symptoms of Valtrex overdose include hallucinations and decreased mentation. V2 said R2's Valtrex dosage was larger than R2 could tolerate. R2's admission Record dated 9/24/24 shows R2's diagnoses include, but are not limited to, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic disease, or end stage renal disease, congestive heart failure, end stage renal disease, and dependence on renal dialysis. R2's Order Summary Report dated 10/11/24 shows and order dated 9/9/24 for Valacyclovir (Valtrex) one gram by mouth every eight hours for cold sores, shingles, or genital herpes for seven days. R2's Medication Administration Record (MAR) for 9/1/24 to 9/30/24 shows R2 began receiving the prescribed Valtrex at 2:00 PM on 9/9/24 and received 12 doses from 9/9/24 to 9/14/24. R2's Progress Notes dated 9/14/24 at 11:57 AM show R2 was lethargic and slow to respond. R2 was sent via ambulance to the hospital. R2's Progress Notes dated 9/14/24 at 9:55 PM show R2 was admitted to the hospital with a diagnosis of altered mental status. R2's History and Physical (H&P) date of service 9/15/24 at 5:28 PM, shows R2 presented to the hospital with altered mental status with minimal responsiveness, herpes simplex infection of the chest wall, and end stage renal disease requiring (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 2 Event ID: 145630 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 145630 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care North Branch 6840 West Touhy Avenue Niles, IL 60714 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)