145730
05/13/2025
Continental Nursing & Rehab Center
5336 North Western Avenue Chicago, IL 60625
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Based on observations, interviews, and record reviews, facility failed to follow their policy to ensure residents received medications according to the physician order for 3 residents (R1, R2, R6) out of of 3 residents reviewed for medication administration in a total sample of 6.
Findings include: On 5/6/2025, at 11:00 AM, surveyor observed R2 in her bedroom. R2 stated that sometimes the nurses take forever to administer medications. R2 stated that today she received her medications. R2 stated that she is not sure when. On 05/06/2025, at 11: 05 AM, surveyor asked V3 to show him the medication administration report for the 3rd floor residents. R1, R2, and R6's medication administration report (MAR) was marked red. Surveyor asked V3 what does it mean when residents' reports are marked 'Red'. V3 stated that if the medication administration report is 'red' that means the nurse has not documented that the medications were given. V3 stated that he is not sure if V4 (Registered Nurse) has administered all her medications yet. On 05/06/2025, at 11:14 AM, R1 stated that he has not received his morning medications yet. On 05/06/2025, at 11: 15 AM, R6 stated that he has not received his scheduled morning medications yet. On 05/06/2025, surveyor observed V4 (Registered Nurse) administering medications to residents on the 3rd floor. R1 received scheduled 9:00 AM medications at 11:47 AM. R6 received scheduled 9:00 AM medications at 11:50 AM: On 05/06/2025, at 11:47 AM, R1 received Vitamin D 1000 MG, cetirizine 5 MG (milligrams) oral and Arginaid 1 Unit packet. On 05/06/2025, at 11:50 AM, R6 received Bupropion 150 MG oral tablet, Enoxaparin Injection, and Topermate 50 MG oral tablet. On 05/06/2025, at 12:00 PM, V4 (Registered Nurse) stated that she knows she administered some medications two hours late today. V4 stated that the expected time to administer medications is within one hour prior and after of the scheduled time. V4 stated it was because she had to escort R2 outside and she got delayed to administering her medications.
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145730
145730
05/13/2025
Continental Nursing & Rehab Center
5336 North Western Avenue Chicago, IL 60625
F 0755
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
On 05/07/2025, at 2:55 PM, V2 (Director of Nursing) stated that the expectation is for nurses to administer medications either, one hour prior and/or one after the scheduled time. V2 stated that nurses are to document immediately after administering medications. V2 stated that if it is not documented then the task was not done. R1, R2 and R6's Minimum Data Sheet Section C (4/10/2025) documents in part: R1, R2 and R6's Brief Interview of Mental Status (BIMS) is 15, which means all three residents are cognitively intact. R6's Medication Audit Report (5/6/2025) documents in part: Enoxaparin Sodium Injection Solution Prefilled syringe. Inject 0.4 ML (milliliters) subcutaneously two times a day for DVT (deep vein thrombosis) prophylaxis. Scheduled time: 5/6/2025, at 9:00 AM. Administration time: 05/06/2025, at 11:43 AM. Bupropion oral tablet 150 MG. Give 1 tab one time a day for Depression. Scheduled time: 5/6/2025, at 9:00 AM. Administration time: 05/06/2025, at 11:43 AM. R2's Medication Audit Report (5/6/2025) documents in part: Depakote oral tablet 250 MG give two times a day for epilepsy. Scheduled time: 5/6/2025, at 9:00 AM. Administration time: 05/06/2025, at 11:56 AM. Clozapine 200 MG tablet, give two times a day for schizophrenia. Scheduled time: 5/6/2025, at 9:00 AM. Administration time: 05/06/2025 at 11:56 AM. Facility Drug Administration Guidelines (undated) documents in part: Medications are administered within 120 minutes of scheduled time, except before or after meal orders. The individual who administered the medication, records the administration on the resident's MAR at the time the medication was given. At the end of each medication pass, the person administering the medication reviews the MAR to ascertain that all necessary doses were administered, and all administered doses were documented.
145730
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