Health inspection·February 6, 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 interview and record review the facility failed to ensure medications were administered timely to 5 of 5 residents (R1-R5) reviewed for medication administration in the sample of 5. The findings include: 1. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. On 2/6/25 at 10:20 AM, R1 was alert in bed. R1 said there has been changes lately. R1 said he used to get his morning meds by 7:30 AM. Now it's been very late. Review of R1's medication administration record (MAR) dated 2/1/25 documents: -R1's Carvedilol tablet 25 mg 1 tablet for hypertension twice daily (BID) to be given at 8AM, 8PM. R1's Carvedilol 8AM dose was given at 12:14 PM. (more than four hours late.) -Doxazosin tablet 4 mg for hypertension BID to be given at 8AM, 8PM. R1's Doxazosin 8AM dose was given at 12:14 PM. (more than four hours late.) -Furosemide tablet for swelling BID 8AM-8PM. R1's 8AM morning dose was given at 12:14 PM. (more than four hours late.) 2. R2's facility assessment dated [DATE] show R2 has no cognitive impairment. On 2/6/25 at 10:30 AM, R2 was alert in bed. R2 said last weekend her medications were given late. Review of R2's MAR dated 2/1/25 documents: -Gabapentin 100 mg 1 capsule BID for neuropathy, 8AM, 8PM. R2's Gabapentin 8AM dose was given at 12:06 PM. (more than four hours late.) -Eliquis 5mg 1 tablet BID to prevent blood clot to be given at 8AM, 4PM. R2's Eliquis 8AM dose was given at 12:06PM. (more than four hours late.) 3. R3's facility assessment dated [DATE] show R3 is alert and able to verbalize her needs. On 2/6/25 at 10:10 AM, R3 was in bed with her oxygen on. R3 said medications are late, it just Page 1 of 3 145703 145703 02/06/2025 Silvis Center for Nursing Rehab & Care 1455 Hospital Road Silvis, IL 61282

F 0755 depends when they get to you. Level of Harm - Minimal harm or potential for actual harm Review of R3's (MAR) dated 2/1/25 documents: Residents Affected - Some - Fluticasone and salmeterol inhaler for chronic obstructive pulmonary disease to be given BID at 8AM, 4PM. On 2/1/25, R3's inhaler 8AM dose was given at 11:35 AM. (3.5 hours late) 4. R4's facility assessment dated 12/27 shows R4 is alert and able to verbalize her needs. On 2/6/25 at 9:40 AM, R4 was sitting in her wheelchair. R4 said there has been times her medication was given to her late, R4 said she was not in pain but would like her meds timely to anticipate the pain. Review of R4's MAR dated 2/1/25 documents: -R4's Hydrocodone 5/325 mg (pain medication) 1 tab BID to be given 8AM, 8PM. On 2/1/25 R4's Hydrocodone that was due at 8AM was given at 11:55 AM. (almost four hours late) 5. On 2/6/25 at 10 AM, R5 was sitting in her wheelchair in her room. R5 said she was fine; she was waiting for her meds. Review of R5's (MAR) dated 2/1/25 documents: -R5's Alprazolam 0.5 mg BID to be given at 8AM, 4PM for anxiety. On 2/1/25, R5's Alprazolam that was due at 8AM was given at 11:02 AM. (three hours late) -R5's Hydralazine 25 mg 1 tablet TID for hypertension. (8AM, 12 PM and 4PM.) The 8AM dose was given at 10:55 AM. (almost three hours late) -R5's Buspirone 15 mg 1 tablet TID for anxiety. (8AM, 12 PM and 4PM.) R5's 8AM dose was given at 10:55 AM. (almost three hours late) On 2/6/25 at 10:30 AM, V3 (License Practical Nurse- LPN) said she worked last 2/1/25 which was a Saturday. She was one of the morning Nurses in the Skilled Unit. That day there was scheduled two Nurses with 24 residents in the skilled unit. V3 said she called V2 (Director of Nursing DON) around 10AM, when the Agency Nurse that was one of the Nurses in the Long Term Care did not show up. V3 said her and the other Short Term/Skilled Unit Nurse (V4) went to the Long Term and administered morning meds. V3 confirmed the morning meds in the long term unit (where R1-R5 were) were administered late. On 2/6/25 at 12:44 PM. V2 (DON) said on 2/1/25 she gave direction that the Skilled Unit only needs 1 nurse (with only 24 residents) and 2 Nurses in the Long Term Unit. It was almost 11AM when the other Nurse moved to the Long Term. V2 said R1-R5 were all residents in the Long Term Unit and their meds were late. V2 said medications should be given an hour before or an hour after it was due. Medications are important to treat residents' sickness and symptoms. The facility policy entitled Medication Administration (undated) states, All medications are administered safely and appropriately to aid residents to overcome illness, relieve and prevent symptoms and help in diagnosis. 19. If the medication is given at a different time from the scheduled time, 145703 Page 2 of 3 145703 02/06/2025 Silvis Center for Nursing Rehab & Care 1455 Hospital Road Silvis, IL 61282

F 0755 update the MAR to reflect administration time. Scheduled medications will be given within an hour window before and after its scheduled and as preferred by resident. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145703 Page 3 of 3