Inspection·February 28, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to prevent misappropriation of medications for five (R1, R2, R3, R4 and R5) of five residents reviewed for misappropriation of medications from a total sample list of five residents reviewed. Residents Affected - Some Findings include: The facility provided Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media policy dated 3/15/18 documents that Misappropriation of Resident Property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident belongings or money without the resident's consent. No person shall misappropriate or steal any resident's property. Any person who becomes aware of any alleged misappropriation or theft of resident property shall report the incident to the Administrator immediately. On 2/27/24 at 3:06PM, V8 (Registered Nurse/RN) said When I began my shift on 2/12/24 I was counting narcotics with the off-going nurse and some of the people's narcotic numbers were unusual. You get to know how much they use when you work on one side a lot. One of the cards documented that R2 had used narcotics and that was very unusual. After the count, I went into R2's record to see if he had a fall or something that would cause him increased pain because I never knew him to take narcotics. I couldn't find anything. Also, I looked at his pain scores and they were zero, but one nurse kept documenting that she was pulling Norco for him. That got me worried, so I started looking at the others who rarely take narcotics like R3. We give R3's pain medication religiously at 5:00AM and then on evenings, only twice a day. She had gotten additional pain medication as close together as two hours. I made copies of these two sheets and then at the end of my shift I gave them to V4 (Registered Nurse/Care Plan Coordinator) who was our manager on duty and told her that I thought she should be aware. On 2/27/24 at 10:29AM, V4 (Registered Nurse/Care Plan Coordinator) said that she was notified by V8 (Registered Nurse) the morning of February 13, 2024. She handed me copies of narcotic count sheets and Medication Administration Records and told me that I needed to look at it. I thanked her and notified V1 (Administrator) and V2 (Director of Nursing) and they began the investigation. On 2/27/24 at 9:15AM, V1 (Administrator) stated that the facility completed an investigation immediately when notified and that as a part of the investigation, V3 (Agency Registered Nurse/RN) was repeatedly contacted and would not return her calls. V1 stated that the results of the investigation yielded narcotic medications for five residents that could not be accounted for. R1's physician order dated 1/29/24 documents, Oxycodone-Acetaminophen (Narcotic) Oral Tablet (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 5 Event ID: 145708 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 145708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Health 2304 C R 3000 N Gifford, IL 61847 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)