Inspection·November 21, 2024

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the pharmacist's Medication Regimen Review (MRR) failed to identify the transcription omission of a resident's thyroid medication for her hypothyroidism diagnosis at the time of her readmission. This applies to 1 of 3 (R1) residents reviewed for pharmacy services. The finding includes: R1's EMR (Electronic Medical Record) showed R1 was discharged from the facility on 8/16/2024 and readmitted on [DATE] after she had an ER (Emergency Room) visit. R1's admission Record sheet showed R1 had an active diagnosis of hypothyroidism identified on 6/17/2024. On 11/15/2024 at 10:45 AM, R1 was interviewed regarding her medications. During the interview, R1 had difficulty expressing her thoughts and became frustrated at times. R1 said she felt confused, and tired and had trouble seeing close objects like her call light. R1 said she was worried because her community physician (V25) informed her she had not been receiving her thyroid medication and now her levels were too high. R1 said she was not sure why her thyroid medication had been missed because she had been taking it for a long time. R1's ER visit documents dated 8/19/2024 showed R1 was discharged back to the facility with the facility's Transfer/Discharge Report dated 8/16/2024. The report included R1's active medications, including Levothyroxine Sodium Tablet 150 MCG. Directions: Give 1 tablet by mouth in the morning for low thyroid hormone. R1's hospital documents were uploaded in her EMR on 8/19/2024. V25's (Physician) 11/8/2024 Physician Report showed R1's elevated TSH (thyroid-stimulating hormone) level of 120 was evaluated. The report said She is on half the dose that I had her listed on my medication list. She is feeling tired fatigue confused and is having some ocular issues and I think a lot of the symptoms could be related to her thyroid. The report showed V25 restarted R1's prior dose of Levothyroxine on 11/8/2024, 79 days later. On 11/19/2024 at 1:00 PM, V19 (Pharmacist Manager Consultant) said Pharmacists performed Medication Regimen Reviews (MRRs) for new admissions and readmissions, and then monthly to review the most recent hospital discharge medication lists and current electronic medical records. V19 said MRRs are done to try to catch medication errors and irregularities. V19 said he reviewed R1's MRRs dated 8/21/2024 when she readmitted , and then performed the following monthly MRRs dated 9/5/2024 and 9/22/2024, and R1's hospital discharge documents dated 8/19/2024. V19 confirmed R1's Levothyroxine medication (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: 145699 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 145699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara of Elgin 1950 Larkin Avenue Elgin, IL 60123 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)