Inspection·August 14, 2024

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a nurse was competent to administer medications as ordered and transcribe orders for 4 of 4 residents (R3, R4, R7 and R8) reviewed for nursing services in the sample of 8. Findings include: 1. R3's Face Sheet shows that she admitted to the facility on [DATE] with diagnoses of: polyneuropathy, schizoaffective disorder, neuromuscular dysfunction of the bladder, anxiety, hypothyroidism, insomnia and hyperlipidemia. R3's Minimum Data Set (MDS) assessment dated [DATE] shows that her cognition is intact. R3's August Medication Administration Record (MAR) shows that she takes lamotrigine (anticonvulsant) 25 milligrams (mg)-3 tablets once daily at 8:00 AM for mood stabilization, aripiprazole (antispychotic) 10 mg daily at 8:00 AM for mood and paranoia and gabapentin (anticonvulsant) 300 mg three times a day at 8:00 AM, 12:00 PM and 6:00 PM for anxiety/pain. On 8/13/24 at 10:05 AM, R3 said that V3 (Registered Nurse) gave her her 8:00 AM medication one day and she was missing 2 of the 3 tablets of lamorigine, her aripiprazole and her gabapentin. R3 said that she had to tell V3 that she was missing them and then she corrected it. 2. R4's Face Sheet shows that she admitted to the facility on [DATE] with diagnoses of: seizures, diabetes mellitus, hypothyroidism, hypertension, edema, gastro-esophageal reflux, high cholesterol, morbid obesity, depression, schizoaffective disorder and obstructive sleep apnea. R4's MDS dated [DATE] shows that her cognition is intact. R4's August MAR shows that she receives the following medications at 8:00 PM: metformin (antidiabetic) 1000 mg, pravastatin (statin) 10 mg, bumetanide (diuretic) 2 mg, divalproex (anticonvulsant) 500 mg, famotidine (acid reducer) 20 mg, levetiracetam (anticonvulsant) 500 mg and ferrous sulfate (supplement) 325 mg. R4's August MAR shows that she receives the following medications at 9:00 PM: mirtazapine (antidepressant) 7.5 mg and olanzapine (antipsychotic) 15 mg. On 8/13/24 at 9:45 AM, R4 said that V3 came to her room awhile back to give her her evening pills. R4 said that she only had 4 pills in the cup and she usually takes 9 pills at bedtime. R4 said she told V3 that she takes more pills than that and she left the room with the pills and then another nurse brought her the correct amount of pills. R4 said that again last Friday, V3 brought her evening pills in and there was only 8 pills in the cup. R4 said that she showed V3 the list of medications (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 3 Event ID: 145825 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 145825 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE South Elgin Living & Rehab Center 746 West Spring Street South Elgin, IL 60177 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)