Health inspection·May 16, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review the facility failed to notify the residents representative psychotropic medications were prescribed. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 4. The findings include: On 5/16/25 at 10:37 AM, V9 (R1's Guardian) said the facility reported R1 was receiving psychotropic medications with my knowledge or consent. V9 said she did not consent for him to receive those medications. When she asked the facility why he was on the medications she was told, R1 would be uncontrollable without the medications. R1's face sheet shows V9 is R1's Guardian. R1's Physician Order Sheets dated May 2025 shows orders including Haloperidol 5 mg (milligrams) every 6 hours as needed for behavior disturbance and Lorazepam 1 mg every 6 hours as needed for behaviors (both order date of 3/4/25). R1's Consent for Psychotropic Medications dated 3/5/25 shows Haloperidol 5 mg and Ativan (Lorazepam) 1 mg listed. The informed consent is signed by V3 (ADON) and signed signature above the resident/authorized Representative/Guardian. On 5/16/25 at 12:10 PM, V3 (Assistant Director of Nursing-ADON) said she over sees psychotropic medications. Consent should be obtained from the resident or resident representative prior to the use of psychotropic medications. At 1:57 PM, V3 said R1 signed his own consent, and she was not aware of R1 having a guardian. V2 (Director of Nursing) confirmed R1 has a guardian, and consents should be signed by the authorized representative. The facility's undated Psychotropic Drug Therapy Policy states, Psychotropic drug therapy will be used only to treat a specific condition .Obtain informed consent. PSYCHOTROPIC MEDICATION SHALL NOT BE PRESCRIBED OR ADMINISTERED WITHOUT THE INFORMED CONSENT OF THE RESIDENT, THE RESIDENTS GUARDIAN OR OTHER AUTHORIZED REPRESENTATIVE . Page 1 of 3 145714 145714 05/16/2025 Oak Park Oasis 625 North Harlem Oak Park, IL 60302

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review the facility failed to ensure prescribed medications were administered as ordered for 1 of 3 residents (R2) reviewed for medication administration in the sample of 4. Residents Affected - Few The findings include: R2's Medication Administration Record dated April 2025 shows orders including Benztropine Mesylate 0.5 mg (milligram) give one tablet at bedtime. The M.A.R. shows on 4/10/25 this medication was not administered. Divalproex Sodium tablet 500 mg ER (extended release) give two tablets at bedtime related to bipolar disorder. The M.A.R. shows this medication was not administered on 4/10/25 and 4/13/25. Olanzapine 10 mg give one tablet daily for mood disorder. The M.A.R. shows this medication was not administered on 4/10/25. Trazadone 50 mg give 1.5 tablet daily for insomnia. The M.A.R. shows this medication was not administered on 4/10/25 and 4/13/25. On 5/16/25 at 9:28 AM, V5 (Registered Nurse) said medications should be administered as ordered. If the medication is given it is documented on the M.A.R. If the M.A.R. shows no entry the medication was not administered. The facility's undated Medication Administration Policy states, Documentation of medication administration is recorded on the Medication Administration record (MAR) or Treatment Record and includes the date, time and initials of the licensed nurse who administered the medication . 145714 Page 2 of 3 145714 05/16/2025 Oak Park Oasis 625 North Harlem Oak Park, IL 60302

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review the failed to ensure stop dates for residents with prn (as needed) psychotropic medications were in place for 2 of 3 residents (R1, R3) reviewed for psychotropic medications in the sample 4. Residents Affected - Few The findings: R1's Physician Order Sheets dated May 2025 shows orders including Haloperidol 5 mg (milligrams) every 6 hours as needed for behavior disturbance and Lorazepam 1 mg every 6 hours as needed for behaviors (both order date of 3/4/25). R3's Physician Order Sheets dated May 2025 shows orders including Lorazepam Injection 0.5 ml every 8 hours as needed for agitation (order date 4/29/25). On 5/16/25 at 12:10 PM, V3 (Assistant Director of Nursing-ADON) said psychotropics prn medications should have a stop date of 14 days. The facility's Psychotropic Drug Therapy undated policy states, Psychotropic drug therapy will be used when necessary to treat a specific condition .PRN (as needed) psychoactive medications will be ordered with a time limit of 14 days. After that time, Physicians may re-evaluate and reroder at 14 day intervals. There must be documentation to support the continued use. 145714 Page 3 of 3