Health inspection·March 24, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer medications in a timely manner and ensure a resident's linens were clean. These failures affect one of three (R8) residents reviewed for quality of care in total sample of eight residents. Residents Affected - Few Findings include: R8 is a [AGE] year-old male. R8's diagnoses are but not limited to critical illness myopathy, type 2 diabetes with diabetic neuropathy, chronic obstructive pulmonary disease, dysphagia, weakness, hypothyroidism, polyneuropathy, atherosclerosis, chronic atrial fibrillation, peripheral vascular disease, end stage renal disease, presence of aortocoronary bypass graft, long term use of anticoagulants, and long-term use of insulin. R8's BIMS (Brief Interview for Mental Status) dated 3/23/2025, notes R8 is alert. R8 was admitted to the facility on [DATE]. R8's care plan notes R8 have potential for difficulty in breathing due to chronic obstructive pulmonary disorder and obstructive sleep apnea. R8 requires the use of statin medication due to hyperlipidemia. R8 has a potential for altered cardiac function due to atrial fibrillation, coronary artery disease, and a history of coronary artery bypass graft surgery. R8's POS (Physician Order Statement) notes Atorvastatin Calcium Oral Tablet 40 mg; give one tablet by mouth one time a day for pure hypercholesterolemia. Cinacalcet Bisulfate Oral Tablet 30 mg; given by mouth one time a day for nutritional support. Clopidogrel Bisulfate Oral Tablet 75 mg; given by mouth one time a day related to presence of aortocoronary bypass graft. Lidocaine External Patch 4%; apply to lower back topically one time a day for pain. Renal-Vite Oral Tablet 0.8 mg; given by mouth one time a day related to end stage renal disease. Senna Oral Tablet 8.6 mg; give two tablets by mouth two times a day for constipation. Fluticasone-Salmeterol 250-50 mcg/act aerosol powder; 2 puffs inhale orally two times a day related to chronic obstructive pulmonary disease. Gabapentin Oral Tablet 100 mg; give one capsule by mouth three times a day related to polyneuropathy. On 3/23/2025, at 11:14 AM, R8 stated, I have been here for a week and a day. I think the nurse did give me medication this morning. I have a problem with my memory. My sheets were changed two days ago. I am ready for them to change them today. On 3/23/2025, at 11:16 AM, R8 pulled back the blankets on his bed. There were dried, dark colored stains on R8's sheets. On 3/23/2025, at 11:42 AM, V11 (Registered Nurse) stated, I have not given (R8) his medication today. There are too many residents. I got here before 7:00 AM. Morning medication pass starts after I Page 1 of 2 145650 145650 03/24/2025 Nexus at Palos 10426 South Roberts Palos Hills, IL 60465

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few get report. I have 18 residents. All of them have gotten their medication except for (R8). When it is in red it means it is overdue. There are some medications I have not given him. Cinacalcet, atorvastatin, gabapentin, and some stool softeners were all supposed to be given at 9:00 AM. Medication is supposed to be given one hour before or one hour after administration time. On 3/23/2025, at 11:44 AM, V11 showed R8's electronic MAR (Medical Administration Record). R8's MAR was all red. V11 stated this means his medications are late. On 3/23/2025, at 11:50 AM, V12 (Assistant Director of Nursing) stated, When my nurses are passing medications, I expect them to follow to the medication rights. They are passed an hour before or after the time frame of when they are due. I expect my nurses to assess the patient, notify the provider for recommendations, and the family to let them know what is going to happen and if there is going to be monitoring, etc. The medications that are late for R8 are: Cinacalcet 30mg (milligrams) is a supplement for dialysis patients, Eliquis 5mg, is an anticoagulant, Atorvastatin 40mg, for his cholesterol, Clopidogrel 75 mg, is an anti-platelet, Fluticasone inhaler, for his lungs, Gabapentin 100mg, for neuropathy, Lidocaine patch for pain, renal vitamins, senna, a stool softer, and an Accu-Chek, for his blood sugar monitoring. All these medications are late because they are red. I expect the aides to change the sheets every shower or if visibly soiled. Resident Council Meeting Minutes dated January 29, 2025; notes residents have concerns about not receiving their medications on time. Resident council meeting minutes dated February 28th, 2024; notes linens need to be changed more often. Facility policy titled Medication Administration, dated 4/2024, notes all medications are administered safely and appropriately to aide residents to overcome illness, relieve, and prevent symptoms, and help in diagnosis. Verify that the medication is being administered at the proper time. Facility policy titled Bedmaking, dated 9/2022, notes to provide a clean, wrinkle-free bed for the comfort of the resident. Complete bed changes are done on shower/bath days and as needed. Bed linens are changed when wet or soiled. 145650 Page 2 of 2