Health inspection·March 24, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 provide care according to professional standards and properly label medication that had been open for resident use. These failures affect one (R1) resident out of three residents reviewed for medications. Residents Affected - Few Findings Include: R1's physician order sheet/POS documents the following orders: Baclofen Tablet 10 MG- Give 1 tablet by mouth one time a day for musculoskeletal therapy agents. On [DATE] at 9:54 AM, V3 (Registered Nurse/RN) stated he has begun his medication administration pass already and is about to prepare R1's medications to administer. A medication bingo card was labeled Baclofen 5 mg, with a residents' name torn off of the label. R1's name was handwritten in black marker on the Baclofen medication bingo card. On [DATE] at 10:04 AM, V3 stated there was an issue with R1's Baclofen medication. V3 stated he was the nurse assigned to care for R1 on [DATE], and noticed R1's Baclofen medication was not available in the facility, and for some reason got lost. V3 stated he then called the pharmacy, and the pharmacy informed him R1's Baclofen medication was dispersed on [DATE], and was not due to be refilled until [DATE]. V3 stated later, the DON/Director of Nursing (identified as V2) brought a substitute bingo card with Baclofen medication inside to administer to R1 until R1's Baclofen medication can be refilled on [DATE]. On [DATE] at 10:41 AM, R1 stated the facility informed her her Baclofen medication was not available in the facility. R1 stated she receives a 10 mg tablet of Baclofen, but the facility only had 5 mg tablets. On [DATE] at 3:41 PM, V11 (General Manager of Pharmacy) stated a 30-day supply of R1's Baclofen 10mg medication was dispensed to the facility on [DATE] at 2:40 PM, and signed by a facility staff member. V11 stated R1's Baclofen 10mg medication cannot be refilled at this time because it is too soon to be refilled. V11 stated since a 30-day supply was dispensed, R1's Baclofen 10mg medication should not have run out and should still be available in the facility. On [DATE] at 4:33 PM, V2 (DON) stated she was just made aware today R1's Baclofen 10mg medication was not available in the facility. V2 stated she is now made aware the nurses tried to reorder R1s' Baclofen medication, but it was too soon to be refilled. V2 stated she also just found out the nurses found a medication bingo card consisting of Baclofen 5mg and felt the need to administer this medication to R1 because they did not want R1 to miss a dose of medication. V2 stated she is aware the (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 4 Event ID: 145659 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 145659 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Waterford Care Center, The 7445 North Sheridan Road Chicago, IL 60626 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)