Health inspection·March 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. Based on interview and record review the facility failed to follow their control substance policy and ensure the medication hydrocodone 5-325 milligrams are documented and accounted for, for two of two residents (R4 and R5) reviewed for controlled medications. Findings include: 1. On 3/12/25 at 3:20pm during survey tour with assist from V4 (Director of Nursing) to observe the practice of counting control substance/narcotics, R4's control drug receipt/record/disposition form was observed to have documented discrepancy below date of 2/18/25. R4's control drug receipt record denotes Hydrocodone 5-325mg was signed out on 2/4/25 at 9a.m., 1p.m., and 9p.m. On 2/5/25 at 10a.m. On 2/6/25 at 2pm, 10pm. On 2/7/25 at 8a.m. and 4p.m. On 2/11/25 at 9a.m, 4p.m. On 2/12/25 at 9a.m, 10p.m. On 2/13/25 at 9a.m, 10p.m, 9p.m. On 2/18/25 at 9a.m, 2p.m. R4's Medication Administration Record dated February 2025 was reviewed, there is no documentation denoting that hydrocodone 5-325mg was administered to R4 on 2/4/25 at 9a.m., 1p.m., and 9p.m. On 2/5/25 at 10a.m. On 2/6/25 at 2pm, 10pm. On 2/7/25 at 8a.m. and 4p.m. On 2/11/25 at 9a.m, 4p.m. On 2/12/25 at 9a.m, 10p.m. On 2/13/25 at 9a.m, 10p.m, 9p.m. On 2/18/25 at 9a.m, 2p.m. R4's physician order sheet shows orders for hydrocodone/APAP tab, 5-325MG (milligrams) give 1 tablet orally every six hours as needed for pain related to chronic pulmonary disease, order start date 11/1/2024. On 3/14/25 at 10:39am V4 said control substance should be signed out on the medication administration record after administration of the medication. Facility policy dated 10/2014 denotes in-part accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administrated, the licensed nurse administering the medication immediately enters the following information on the accountability record and medication administration record (MAR): date and time of administration. (MAR and accountability record). Amount administered. (accountability record). Remaining quantity. (accountability record). Initials of the nurse administering the dose, completed after the medication is actually administered. (MAR, accountability record). 2. On 3/12/25 at 3:20pm during survey tour with assist from V4 (Director of Nursing) to observe the practice of counting control substance/narcotics, R5's control drug receipt/record/disposition form was observed to have documented discrepancy below date of 2/18/25. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145781 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145781 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Generations at Applewood 21020 Kostner Avenue Matteson, IL 60443 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)