Health inspection·October 30, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medications as ordered by the prescriber and in a timely manner for four of four residents (R1, R2, R3, R4) reviewed for medication administration in a sample list of eleven. Findings include: 1.) On 10/29/24 at 2:36 PM, R1 stated the nurses give her medications at different times. R1 stated R1 never knows when she will get her medications or what she is getting. R1 stated, she has been woken up in the middle of the night to get medications but states she does not take any medications that late. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. R1's October 2024 Medication Administration Record (MAR) documents orders for R1's medications as follows: at 8:00 AM every morning, R1 is to receive Cholecalciferol (vitamin D) 25 micrograms (mcg), Amiodarone (anti-arrhythmic) 200 milligrams (mg), Furosemide (anti-hypertensive) 20 mg, Multivitamin 1 capsule, Apixaban (anticoagulant) 5 mg, Metoprolol (hypertension/heart failure) 25 mg, Omeprazole (anti-reflux) 40 mg, Ocular Vite (eye vitamin) 1 capsule, Losartan Potassium (anti-hypertensive) 50 mg, and Acidophilus (probiotic) 1 capsule via gastrointestinal tube (G-tube). At 4:00 PM every afternoon, R1 is to receive Apixaban 5 mg, and Ocular Vite. At 8:00 PM everyday, R1 is to receive Omeprazole 40 mg, Duloxetine (anti-depressant) 30 mg, and a Scopolamine (anti-nausea) 1.5mg patch. R1's Medication Admin Audit Report dated 10/30/24 documents: 10/1/24 8:00 PM ordered medications administered at 11:16 PM. 10/4/24 8:00 PM ordered medications administered at 10:27 PM. 10/17/24 8:00 PM ordered medications were administered at 10:14 PM 10/18/24 8:00 PM ordered medications administered at 10:11 PM. 10/24/24 4:00 PM ordered medications were not administered. 10/25/24 8:00 AM ordered medications were administered at 10:38 AM Page 1 of 4 145772 145772 10/30/2024 Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938

F 0755 10/25/24 8:00 PM ordered medications administered at 11:23 PM Level of Harm - Minimal harm or potential for actual harm 10/28/24 4:00 PM ordered medications administered at 7:10 PM 10/28/24 8:00 PM ordered medications administered 10/29/24 at 12:13 AM Residents Affected - Some 10/29/24 8:00 PM ordered medications administered at 10:10 PM. There is no documentation in R1's medical record that R1's physician was notified of the late or missed doses of medications. 2.) On 10/29/24 at 2:55 PM, R2 stated she gets her medications at all different times. R2's MDS dated [DATE] documents R2 as cognitively intact. R2's undated care plan documents R2 is at risk for hypothyroid with interventions to administer medication as ordered; R2 is at risk for cardiac arrhythmia's related to decreased cardiac output with interventions to administer medications as ordered. R2's October 2024 Medication Administration Record documents orders for R2 to receive Levothyroxine (thyroid hormone) 125 mcg at 7:00 AM every morning, that R2 is to receive Lisinopril (anti-hypertensive) 5 mg, Loratadine (antihistamine) 10 mg, Multivitamin 1 capsule, Carvedilol (hypertension/heart failure) 12.5 mg, and Doxycycline Hyclate (antibiotic) 100 mg (10/8-10/15/24 only) at 8:00 AM every morning, and that R2 is to receive Doxycycline Hyclate 100 mg (10/8-10/15/24 only), and Carvedilol 12.5 mg at 8:00 PM every evening by mouth. R2's Medication Admin Audit Report dated October 2024 documents the following administration times: 10/9/24 8:00 PM medications administered at 10:10 PM 10/11/24 8:00 PM medications administered at 10:56 PM 10/17/24 7:00 and 8:00 AM medications administered together at 9:28 AM 10/22/24 8:00 PM medications administered at 10:47 PM 10/23/24 8:00 PM medications administered at 10:04 PM 10/28/24 8:00 PM medications administered 10/29/24 at 12:38 AM There is no documentation in R2's medical record that R2's physician was notified of the late doses. 3.) R3's care plan undated, documents R3 is at risk for gastrointestinal distress, hyper cholesterol, hypertension, and psychotic episodes with interventions to give medications as ordered. R3's October 2024 Medication Administration Record documents orders for R3 to receive Seroquel (anti-psychotic) 25 mg, Colace (stool softener) 100 mg, and Cyanocobalamin (vitamin B) 500 mcg at 8:00 AM every morning and Seroquel 25 mg and Flomax (enlarged prostate) 0.4 mg at 8:00 PM every evening. 145772 Page 2 of 4 145772 10/30/2024 Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938

F 0755 R3's Medication Admin Audit Report dated 10/30/24 documents the following actual administration times: Level of Harm - Minimal harm or potential for actual harm 10/7/24 8:00 PM medications administered at 10:07 PM 10/23/24 8:00 AM medications administered at 10:17 AM Residents Affected - Some 10/30/24 8:00 AM medications administered at 10:40 AM There is no documentation in R3's medical record that R3's physician was notified of the late doses. 4.) R4's undated Care Plan documents R4 has altered skin integrity, hypertension, hyperlipidemia, takes psychoactive medications and interventions include to take medications as ordered. The Care Plan documents R4 is at risk for gastrointestinal distress and interventions include to take medications as ordered. R4's October 2024 Medication Administration Record documents orders for R4 to receive Pantoprazole (anti-reflux) 20 mg, artificial tears eye drops, Prednisone (steroid) 5 mg, Vitamin D3 1 capsule, Minocycline (antibiotic) 50 mg, Colace 100 mg, Mirabegron ER (bladder spasms) 50 mg, Valsartan (anti-hypertensive) 40 mg, Carvedilol 3.125 mg, Claritin 10 mg, and Calcium 600 + D 600-400 mg-unit at 8:00 AM every day. At 4:00 PM every day, R4 is to receive Minocycline 50 mg, Colace 100mg, Carvedilol 3.125 mg, and Calcium 600 + D 600-400 mg-unit. R4 is to receive Aspercreme (pain) 10%, Flonase (allergy) 2 sprays, artificial tears, Systane drops, Mirtazapine (antidepressant) 7.5 mg, Senna tablet (stool softener) 8.6 mg, and Simvastatin (lipid lowering) 20 mg at 8:00 PM every evening. R4's Medication Admin Audit Report dated 10/30/24 documents the following actual administration times: 10/2/24 8:00 PM Aspercreme administered on 10/3/24 at 12:33 AM, 10/7/24 8:00 PM Aspercreme administered on 10/8/24 at 7:43 AM 10/19/24 8:00 PM medications administered at 10:03 PM 10/27/24 8:00 AM medications administered at 10:28 AM There is no documentation in R4's medical record that R4's physician was notified of the late doses. 10/30/24 1:20 PM, V5 Licensed Practical Nurse stated she often gives medications later than scheduled times due to being busy with other tasks throughout the night. On 10/30/24 at 1:05 PM, V2 Director of Nurses stated medications should be passed within two hours of the physician ordered time. On 10/30/24 at 3:30 PM, V3 Registered Nurse stated the standard of care for medication pass times to her knowledge is an hour before to an hour after physician ordered medication time. 145772 Page 3 of 4 145772 10/30/2024 Odd Fellow-Rebekah Home 201 Lafayette Avenue East Mattoon, IL 61938

F 0755 The Facility policy titled Medication Administration policy dated 1/11/10 documents It's the policy of this facility to accurately administer medication following physician's orders. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145772 Page 4 of 4