Health inspection·February 14, 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 ensure medication was administered as scheduled per physician order to 1 (R1) out of 3 residents reviewed for medication administration. Findings Include: R1's face sheet shows included diagnoses but not limited to insomnia and anxiety disorder. R1's Minimum Data Set, dated [DATE], shows R1 is cognitively intact with BIMS (Brief Interview for Mental Status) of 15. R1's Medication Admin Audit Report, printed on 2/11/25 at 11:21 AM, shows ]on 1/27/25, R1 had ordered and scheduled medication Zolpidem Tartrate (Ambien) 10 mg by mouth at bedtime for Insomnia, Seroquel 200 mg 1 tablet by mouth, and Tamsulosin 0.4 mg 1 capsule by mouth all to be administered at 9:00 PM, but were documented administered at 10:35 PM, more than one hour past the scheduled administration time. This Medication Admin Audit Report also revealed R1 had ordered and scheduled medications of Gabapentin 400 mg 1 capsule by mouth three times a day, Hydralazine 25 mg 1 tablet by mouth three times a day, Amitriptyline 100 mg 1 tablet by mouth two times a day, Baclofen 10 mg 1 tablet by mouth two times a day, Hydroxyzine 50 mg 1 tablet by mouth three times a day, and Gabapentin 600 mg 1 tablet by mouth three times a day all scheduled to be administered at 5:00 PM, but were documented administered at 6:49 PM. A review of R1's electronic health records (EHR) does not show any documentation the physician was notified of the late medication administration for R1. On 2/11/25 at 10:09 AM, R1 stated a couple of weeks ago around 8:00 PM, R1 asked V9 (Licensed Practical Nurse) for Ambien (Hypnotic medication) that helps R1 sleep. R1 stated R1 has insomnia due to generalized pain. R1 stated V9 did not give R1 the Ambien, stating it was not available. R1 stated the next morning, R1 asked V6 (Licensed Practical Nurse/LPN) and V6 stated the Ambien was available. On 2/11/25 at 10:22 AM, V6 (Licensed Practical Nurse/LPN) stated R1 does not refuse medications and knows all his meds. V6 stated about three weeks ago, V6 came in the morning, and R1 told V6 that R1 didn't get the Ambien in the evening. V6 stated when V6 checked the narcotic box, R1's Ambien was available. On 2/11/25 at 12:31 PM, V3 (Director of Nursing) stated by mouth medications should be administered to residents one hour before or one hour after. V3 stated the nurses follow the doctor's orders and should follow the right patient, right medication, right route, right time, right dose, and right documentation. V3 stated the right time means it is administered one hour before and one hour after Page 1 of 2 145765 145765 02/14/2025 Park View Rehab Center 5888 North Ridge Chicago, IL 60660

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the scheduled order. V3 stated nurses are documenting in the electronic health records after they administer the medications to the resident. They would also document if it's not given or refused. V3 stated the doctor should be notified if medication is given late, and document in the resident's chart. On 2/11/25 at 3:15 PM, V9 (Licensed Practical Nurse) stated R1 would always ask for R1's sleeping medication around 7:00 PM, and V9 would give it to R1 because it's scheduled at 8:00 PM. V9 stated medications are administered one hour before and one after its scheduled time. V9 stated once V9 administers the medication, V9 will sign in the electronic medication administration record the time it was given to the resident. The facility's MEDICATION ADMINISTRATION POLICY, dated 8/15, documented: Medications must be administered in accordance with a physician's order at his/her discretion, e.g., the right resident, right medication, right dosage, right route, and right time. 145765 Page 2 of 2