Health inspection·June 9, 2025

F 0760 Ensure that residents are free from significant medication errors. 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 ensure residents were free from significant medication errors. This applies to 2 of 3 residents (R1, R2) reviewed for medications in the sample of 4. Residents Affected - Few The findings include: 1. On 6/9/25 at 11:38 AM, R2 was observed in his room sitting in his wheelchair. There were several snacks on his bedside table. R2 said he eats those when his blood sugar is low. On 6/9/25 at 12:11 PM, V6 (Licensed Practical Nurse-LPN) said R2 is a brittle diabetic, and his blood sugars are all over the place. R2 gets long-acting insulin twice a day, and short acting before meals. V6 said she waits to check his blood sugar before meals. V6 stated, (R2's) blood sugar was 133, it's below 150, so he does not get insulin. V6 said she follows the physician orders on how much insulin to administer. On 6/9/25 at 2:41 PM, V9 (R2's Guardian/family member) said R2 is a brittle diabetic, and she does not believe the nurses are giving him the correct insulin doses and the facility is not following the physician orders. V9 said she has expressed her concerns with V1 (Administrator). R2's Endocrinology After Visit Summary, dated 5/15/25, shows orders to increase Tresiba (Long-Acting Insulin) to 70 units at 8:00 AM and decrease Tresiba bedtime dose to 50 units. No need to give the fixed dose of Novolog (short acting insulin). Revise the Novolog scale as follows: (The same report shows it was noted by nursing dated 5/15/25). Blood Sugar Novolog Dose <150 None 151-200 6 units 201-250 8 units 251-300 12 units 301-350 14 units 351-400 18 units Page 1 of 2 145702 145702 06/09/2025 Fair Oaks Rehab & Healthcare 1515 Blackhawk Boulevard South Beloit, IL 61080

F 0760 >400 22 units Level of Harm - Minimal harm or potential for actual harm R2's Medication Administration Record (MAR), dated May 2025 and June 2025, shows orders including Novolog Solution 100 Unit/ML (Milliliters) Inject as per sliding scale: Residents Affected - Few If 151-200= 4 units 201-250= 6 units 251-300= 8 units 301-350= 10 units 351-400 = 12 units 401+ = 14 units, notify POA and MD if over 500. (Start date 4/8/25; DC date 6/7/25). (The MAR does not shows the revised sliding scale orders from 5/15/25). On 6/9/25 at 3:00 PM, V3 (Asssistant Director of Nursing/ADON) said nursing should verify all orders are carried out, and confirmed R2's sliding scale orders did not get changed from 5/15/25. 2. R1's face sheet shows she is an [AGE] year-old female admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, COPD, cirrhosis of liver, cognitive communication deficit, acidosis, anxiety, hypertension, occlusion and stenosis of the carotid artery. R1's Medication Administration Record for April 2025 shows orders including Rifaximin (antibiotic) oral tablet 550 mg (milligrams) one tablet twice a day for hepatic encephalopathy. The MAR shows on 4/16/25, R1 did not receive both doses. On 6/9/25 at 1:30 PM, V3 (ADON) said they received a ten day supply of R1's antibiotic (Rifaximin), and the medication was not given on 4/16/25 because they did not have the medication. Nursing should re-order medications at least a few days prior before the last dose. The facility's undated Medication Administration Policy for Senior Living states, All medication orders must be prescribed by a licensed healthcare professional and documented accurately in the residents' medical records .Any changes in medication orders must be documented in the resident's medical record .Medications should be administered according to the five rights of medication use: right resident, right drug, right time, right dose and the right route . 145702 Page 2 of 2