Health inspection·June 27, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer intravenous (IV) antibiotic medication as ordered by Physician for one (R3) resident with diagnosis of Osteomyelitis. This failure affected one (R3) of three residents reviewed for pharmaceutical services. The findings include: R3's admission record showed admit date on 6/12/2025 with diagnoses not limited to Osteomyelitis, Paraplegia, Depression, Bipolar disorder, Anxiety disorder, Essential (primary) hypertension, Neuromuscular dysfunction of bladder, Neurogenic bowel, Contact with and (suspected) exposure to other viral communicable diseases. MDS (Minimum Data Set) dated 6/19/2025 showed R3's cognition was intact. On 6/25/25 at 11:58AM Observed R3 sitting up on bed, alert and oriented x 3, verbally responsive, appears comfortable, with multiple wounds on both lower legs. He said he was admitted to the facility on [DATE] between 4-5pm for IV antibiotic treatment due to wound infection on sacral area. R3 stated he was on IV Meropenem 3 times per day and IV Vancomycin 3 times per day. He said he was supposed to get IV Vancomycin on the day he came to the facility on 6/12/25 and the following day 6/13/25 but he did not get it, and he missed a total of 4 doses. R3 said IV Vancomycin was started on 6/14/25 and he completed IV antibiotic treatment on 6/20/25. On 6/26/25 at 11:40 AM, V2 (DON / Director of Nursing) stated he has been in the facility for about nine years. He said R3 should continue the IV ABT (antibiotic) Vancomycin as ordered by the physician upon admission. V2 stated it is important to administer the medication, the potential effect is that the cycle will be incomplete and the ABT (antiboitic treatment) may not treat the infection as prescribed by the physician. V2 stated that the IV Vancomycin was available in the (automated medication and supply management system) and it should have been administered or a call to the pharmacy could have taken place for a STAT (emergency) order to be delivered. V2 said per MAR (Medication Administration Record) Vancomycin IV was not administered on 6/12/25 and 6/13/25, it was started on 6/14/25. R3's hospital records (summary of discharge medications) dated 6/12/25 showed order not limited to: Vancomycin 1gm inject into the vein every 8 hours for 7 days. End of treatment 6/17/25. Schedule: 12AM, 8AM, and 4PM. Last dose given on 6/12/25 at 10:37AM. R3's order summary report dated 6/25/25 showed order not limited to: Vancomycin HCl Intravenous Page 1 of 2 145730 145730 06/27/2025 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 Solution Reconstituted 1 GM (gram) (Vancomycin HCl) Use 1000 mg (milligrams) intravenously every 8 hours for antibiotic for 7 Days 1000mg into vein every 8 hours. Order date 6/13/25. R3's MAR (Medication Administration Record) showed Vancomycin HCl Intravenous Solution Reconstituted 1 GM (Vancomycin HCl) Use 1000 mg intravenously every 8 hours for antibiotic for 7 Days 1000 mg into vein every 8 hours. Schedule time at 6AM, 2PM and 10PM. IV Vancomycin was signed as given or started on 6/14/25 and was completed on 6/20/25. R3's Nursing Progress Note by V6 (Licensed Practical Nurse / LPN) dated 6/12/2025 showed in part: R3 admitted to facility in stable condition with Contact Isolation, wound all over his body and big wound in the sacral area. R3 came with a PICC line one lumen in the right arm for IV antibiotic. R3's progress notes reviewed and did not reflect that IV Vancomycin was given on 6/12/25 and 6/13/25. R3's care plan dated 6/13/25 showed in part: IV meds (medications). R3 has PICC (peripherally inserted central catheter) line on right arm related to wound infection. Administer medication as ordered. Facility's pharmacy delivery schedule and cut off times information (an automated medication and supply management system) showed in part: STAT as requested 2-4 hour turn around. Facility's list of medications available in the cubex showed but not limited to: Vancomycin 1gm, Vancomycin 500mg, Vancomycin 750mg, Vancomycin 125mg, Meropenem 500mg. Facility's Drug Administration - general guidelines policy (undated) showed in part: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by personas legally authorized to do so. Medications are prepared, administered, and recorded only licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations. Medications are administered in accordance with written orders of the attending physician. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Facility's physician order policy (undated) showed in part: It is the policy of the facility to follow the orders of the physician. 145730 Page 2 of 2