Health 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 Page 1 of 2 145692 145692 02/07/2025 Axiom Healthcare of Flora 232 Given Street Flora, IL 62839

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few didn't feel right and that it felt tingly / stinging. V11 stated that she immediately wiped it off and told the nurse. V11 stated that V12 then applied cream to R1. On 02/06/2025 at 2:07 P.M. V10 (Registered Nurse) stated that she was working the night shift on 1/31/2025 and had put the gel on R1's knee. V10 stated there had been an emergency and she left the cup sitting in R1's room with the leftover gel in it. V10 stated with the distraction of the emergency she forgot to go back and get the cup and throw it away. On 02/06/2025 at 2:17 P.M. V12 (Registered Nurse) stated she was the nurse taking care of R1 when V11 put cream on his abdominal fold. V12 stated V11 was in the room providing care to R1 when she put cream that was in an unlabeled cup on R1's abdominal fold. V12 stated that the resident immediately told the staff that it was stinging and they wiped it off. V12 stated the cream was on R1 for 2-3 minutes max. V12 stated that R1's skin had no adverse effects from the wrong cream being put on. V12 stated the correct treatment of the barrier cream was then applied. V12 stated that it is the facility policy to not leave medications in cups at the bedside. The facility policy titled Storage of Medications (undated) documented under Policy - Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure step 1 documents The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medication to the original container. 145692 Page 2 of 2