Inspection·February 7, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medications were properly labeled and not accessible to residents and unlicensed staff for 1 (R1) of 4 residents reviewed for medication storage in the sample of 4. The Findings Include: R1's admission Record documented that R1 is a [AGE] year-old that was admitted to the facility on [DATE] with diagnoses listed as acute cystitis, pain in left knee, need for assistance with personal care, unspecified osteoarthritis, type 2 diabetes mellitus, essential hypertension, pain in joint and localized edema. R1's MDS (Minimum Data Set) with a date of 02/04/2025, documented as an admission set coded section C0500 BIMS (Brief Interview for Mental Status) score of 15 indicating R1 is cognitively intact. R1's Order Summary Report with a print date of 02/07/2025 documented an order for diclofenac sodium (topical Nonsteroidal Anti-inflammatory Drug/NSAID) external gel 1%, apply to left knee, four times a day for left knee pain with a start date of 01/29/2025. On 02/06/2025 at 9:06 A.M. R1 stated there was a cup of cream left at his bedside that V11 (Certified Nurse Assistant/CNA) applied to his abdominal fold. R1 stated that as soon as it was placed on his skin, he knew it was the wrong cream because he felt tingly and hot. R1 stated that V11 immediately cleaned it off and V12 (Registered Nurse) applied the appropriate cream to his abdominal folds. On 02/06/2024 at 12:34 P.M. V2 (Director of Nursing) stated that she thinks what happened with R1 and the cream incident was the nurse left the diclofenac sodium gel in a cup that she had used on his knee. The nurse did not discard the cup with the excess gel in it. V2 stated that during the day on 02/01/2025, the CNA's were in the room providing care to R1 and just automatically placed the cream in his abdominal folds not knowing what it was. V2 stated that it is her expectation that cream not be left at the bedside in unlabeled cups. On 02/06/2025 at 1:31 P.M. V11 (Certified Nurse Assistant) stated on 02/01/2025 she was providing care to R1. V11 stated that R1 was a little red under his abdominal fold and she noticed a cup of cream on the bedside table. V11 stated the cup was not labeled with what the contents were. V11 stated that she just picked up the cream and applied it to R1. V11 stated that she thought the cream in the cup was the barrier cream to be applied to R1's abdominal fold. V11 stated that R1 said that it (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: 145692 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 145692 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Axiom Healthcare of Flora 232 Given Street Flora, IL 62839 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)