Health inspection·January 5, 2026

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on observation, interview and record review the facility failed to notify a resident's representative prior to starting a cognitively impaired resident on a new medication for 1 of 3 residents (R1) reviewed for resident notification of changes and/or treatments in the sample of 3.The findings include:R1's care plan dated 6/6/25 showed R1 was cognitively impaired related to her diagnoses of dementia and multiple sclerosis. The plan showed R1 was very forgetful. The plan showed all information provided to R1 should be provided directly to her advocate.R1's Power of Attorney (POA) for Health Care form dated 9/12/24 showed V7 (Family of R1) was R1's POA. On 1/5/26 at 8:32 AM, V7 (Family of R1) stated R1 was started on Losartan (medication to treat high blood pressure) in August 2025 however, V7 was not notified that R1 had been started the medication until 12/17/25. V7 stated, No one told me (R1) was even having high blood pressures. I am in the facility at least twice a week. I just happened to be talking to the cardiology nurse practitioner (on 12/17/25) when she informed me that (R1) had been on Losartan for high blood pressure. I had no idea. I have told the facility multiple times they are to call me with any changes. No one from the facility notified me of any of this despite it being all over (R1's) chart they are to call me day or night with any changes, including medications. V7 stated R1 is cognitively impaired and cannot remember what medications she is taking. Physician progress notes and a physician order, both dated 8/8/25 for R1, showed R1 was started on Losartan 25 mg (milligrams) once a day due to a new diagnosis of hypertension. The physician note showed the new medication was discussed with R1; however, the note showed no documentation V7 (Family of R1) was notified of R1's elevated blood pressures and/or R1 being started on Losartan.A cardiology note dated 12/17/25 showed the cardiology nurse practitioner contacted V7 (Family of R1) who reported that she (V7) was not aware R1 had taking Losartan for high blood pressure. On 1/5/26 at 10:15 AM, R1 was in bed. R1 was awake but confused to place and time. When R1 was asked what month it was, R1 responded, Sunday. R1 stated she didn't know if she was on a medication for high blood pressure. R1 stated, I don't know. They talk to (V7 Family of R1) about all my medications. On 1/5/26 at 10:03 AM, V3 Social Services stated, I have always known (R1) as confused and forgetful. Her short-term memory is impaired. (V7 Family of R1) is very involved in (R1's) care. (V7) has stated multiple times she wants to be informed of any changes involving (R1).On 1/5/26 at 11:35 AM, V2 Director of Nursing (DON) stated if a resident is started on a new medication, the resident and/or resident representative should receive education on the medication and consent to taking the medication prior to administration of the medication. V2 stated a resident's representative should be contacted if the resident is cognitively impaired. V2 stated R1 was confused, V2 stated V7 (Family of R1) had requested to be notified of any medication or condition changes for R1. V2 stated the facility did not notify V7 prior to starting R1 on Losartan in August 2025. V2 stated, (V7) was not notified that (R1) had been on Losartan for high blood pressure until December (2025). Best practice would have been that we had notified (V7) of the new medication for (R1) prior Page 1 of 2 145819 145819 01/05/2026 Warren Barr Buffalo Grove 150 North Weiland Road Buffalo Grove, IL 60089

F 0580 to starting the medication in August (2025). Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145819 Page 2 of 2