Health inspection·September 24, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to follow its Medication Administration Policy by failing to administer medications in a timely manner. This applies to four of 15 residents (R2, R7, R4 and R5) reviewed for medication administration in a sample of 15.The Findings include:On 9/23/25 at 10:12 AM, V6 (Licensed Practical Nurse/LPN) was passing medication and stated, I have 10 more residents (R2, R3, R4, R7, R8, R9, R10, R11, R14, and R15) to pass the morning medications, which were supposed to be administered at 8:00 AM. We are supposed to administer medications within 2-hour window (one hour before and one hour after) around the scheduled time. I would be able to finish by 10:45 AM.R2 is an [AGE] year-old female with moderate cognitive impairment as per MDS dated [DATE]. On 9/24/25 at 12:30 PM, R2 stated (with Spanish interpreter V8/Housekeeping), I don't know what time I received my medications today. I would like to get my medications on time.A review of the R2's POS and MAR indicates that R2 was scheduled to get the prescribed medications at 8:00 AM including Amlodipine 10 milligram (mg) daily, Aspirin 81 mg daily, Losartan Potassium 25 mg daily, Eliquis 5 mg twice per day (BID), Metoprolol 100 mg daily, Lasix 80 mg BID, and Gabapentin 300 mg three times a day (TID).R7 is a [AGE] year-old male with intact cognition, as per the MDS dated [DATE]. On 9/23/25 at 12:40 PM, R7 stated, The morning medication should come around 8:00 AM, and I got it around 10:30 AM today. I would like to get my medications on time. Today it was late by two and a half hours.A review of the R7's POS and MAR indicates that R7 was scheduled to get the prescribed medications at 8:00 AM, including Amlodipine 10 mg daily, Hydrochlorothiazide 12.5 mg daily, Lisinopril 40 mg daily, and Gabapentin 300 mg three times a day (TID).R4 is an [AGE] year-old male having intact cognition as per the MDS dated [DATE]. On 9/23/25 at 12:45 PM, R4 stated, The morning medications were delayed today, not all the time. I prefer to get my medication on time.A review of the R4's POS and MAR indicates that R4 was scheduled to get the prescribed medications at 8:00 AM, including Amlodipine 7.5 mg daily.On 9/23/25 at 10:20 AM, V7 (Registered Nurse/RN) was passing morning medications and stated, I have three more residents (R5, R12, and R13) to pass 8:00 AM medications. I am sorry, I am late today, because one of my residents was getting shortness of breath and stomachache.R5 is a [AGE] year-old male admitted with mild cognitive impairment as per the MDS dated [DATE]. On 9/23/25 at 12:50 PM, R5 stated, I would prefer to get my medications on time. It was delayed today.A review of the R5's POS and MAR indicates that R5 was scheduled to get the prescribed medications at 8:00 AM, including Ferrous Sulfate Elixir 220 mg (Fe 44)/5milliliter(ml) (Give 7.5 ml) daily, Potassium Chloride 20 milliequivalent (mEq) daily, and Terazosin 2mg daily.On 9/23/25 at 10:25 AM, V5 (LPN) was passing morning medications and stated, I have one more resident (R6) to give 8:00 AM medications. I have residents going out for appointments, and I must prepare them. That's the way I got delayed.A review of the facility's Medication Administration policy, dated September 2018, reveals that, at a minimum, the 5 rights - right patient, right drug, right dose, right route, and right Page 1 of 2 145660 145660 09/24/2025 Aperion Care Westchester 2901 South Wolf Road Westchester, IL 60154

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some time - should be applied to all medication administration.On 9/24/25 at 9:39 AM, V2 (Director of Nursing) stated, Our staff supposed to follow the five rights of medication administration, including right patient, right drug, right dose, right route, and right time. On 9/23/25 at 11:00 AM, V2 added, Our staff is supposed to pass medications within a two-hour window around the scheduled time (one hour before and one hour after the scheduled time). We will in-service all our nurses and change the administration time from 8:00 AM to 9:00 AM. 145660 Page 2 of 2