Health inspection·June 20, 2023

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to notify the Physician of medications that were not administered in 2 of 6 residents (R2, R6) reviewed for Physician notification in the sample of 6. Findings include: 1. On 6/16/23 at 1:25 PM, R6 stated, sometimes they give her medicine to her at night and sometimes they don't. Stated, she doesn't remember the exact dates, but she told the staff in resident council that she wasn't getting her medications at night. The resident Council Minutes, undated, document R6 had her pills put on her table while she was asleep, they spilled during the night, and she did not get her medications. R6's Face Sheet, undated, documents, R6 has a diagnosis of End Stage Renal Disease, Type 2 Diabetes, Hypertension, Anxiety, Anemia, Pain, Major Depressive Disorder and Chronic Respiratory Failure. R6's Minimum Data Set, (MDS), dated [DATE], document R6 is cognitively intact. R6's Care Plan, dated 8/16/19, documents, the following: R6 has Diabetes and to administer insulin as order; R6 has anxiety, depression, insomnia and to administer buspirone 15 milligrams (mg) 3 times daily as ordered. R6's Physician Order Sheets, (POS), documents the following orders: 6/11/21 - Aspirin 81mg daily; 3/31/23 - Buspirone 15mg 3 times daily; 6/11/21 - Lantus 12 units twice daily; 4/29/22 - Montelukast 10mg daily; 3/30/23 - Pantoprazole 40mg daily and 10/26/22 - Renvela 800mg 3 times daily. R6's Medication Administration Record, (MAR), documents, the following: 4/20/23 - Buspirone and Montelukast was not given 10 times and the Pantoprazole was not given 6 times in the month of April; 5/2023 - Aspirin, Lantus and Pantoprazole was not given 7 times, the Buspirone was not given 6 times and the Renvela was not given 14 times in the month of May; 6/2023 - Aspirin, Lantus and Pantoprazole was not given 7 times, Buspirone was not given 2 times and Renvela was not given 9 times in the month of June. R6's Progress Notes were reviewed and there is no documentation, that R6's physician was notified of the medications that were not administered. 2. R2's Face Sheet, undated, documents a diagnosis of Dementia, Hemiparesis/Hemiplegia following a Page 1 of 4 145837 145837 06/20/2023 Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363

F 0580 Cerebral Infarction, Severe Protein-Calorie Malnutrition and Anxiety Disorder. Level of Harm - Minimal harm or potential for actual harm R2's MDS, dated [DATE], documents R2 had severe cognitive impairment. Residents Affected - Few R2's Care Plan, dated 4/12/23, documents R2 has chosen to receive hospice care related to failure to thrive. R2's POS, documents the following orders: 6/15/23 - Lorazepam, (Ativan), 0.5mg every 12 hours. R2's MAR, documents the following: Lorazepam was not given 2 times in May 2023 and 2 times in June 2023. R2's Progress Notes were reviewed and there is no documentation that R2's physician was notified of the medications that were not administered. On 6/20/23 at 9:50 AM, V2, Director of Nurses, stated, if a medication is given or not given, it is documented on the MAR. Stated, if a medication is not given the physician should be notified and a progress note should be recorded. The Medication Errors and Drug Reactions policy, dated 2/2004, documents Medication errors and drug reactions must be reported immediately. Call attending Physician. An entry of the incident must be made on the resident clinical record. 145837 Page 2 of 4 145837 06/20/2023 Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363

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, observation and record review, the facility failed to administer medications as ordered in 2 of 6 residents (R2, R6) reviewed for medications in the sample of 9. Findings include: 1. On 6/16/23 at 1:25 PM, R6 stated, sometimes they give her medicine to her at night and sometimes they don't. Stated, she doesn't remember the exact dates, but she told the staff in Resident Council that she wasn't getting her medications at night. The resident Council Minutes, undated, document R6 had her pills put on her table while she was asleep, they spilled during the night, and she did not get her medications. R6's Face Sheet, undated, documents, R6 has a diagnosis of End Stage Renal Disease, Type 2 Diabetes, Hypertension, Anxiety, Anemia, Pain, Major Depressive Disorder and Chronic Respiratory Failure. R6's Minimum Data Set, (MDS), dated [DATE], document, R6 is cognitively intact. R6's Care Plan, dated 8/16/19, documents, the following: R6 has Diabetes and to administer insulin as order; R6 has anxiety, depression, insomnia and to administer buspirone 15 milligrams (mg) 3 times daily as ordered. R6's Physician Order Sheets, (POS), documents the following orders: 6/11/21 - Aspirin 81mg daily; 3/31/23 - Buspirone 15mg 3 times daily; 6/11/21 - Lantus 12 units twice daily; 4/29/22 - Montelukast 10mg daily; 3/30/23 - Pantoprazole 40mg daily and 10/26/22 - Renvela 800mg 3 times daily. R6's Medication Administration Record, (MAR), documents, the following: 4/20/23 - Buspirone and Montelukast was not given 10 times and the Pantoprazole was not given 6 times in the month of April; 5/2023 - Aspirin, Lantus and Pantoprazole was not given 7 times, the buspirone was not given 6 times and the Renvela was not given 14 times in the month of May; 6/2023 - Aspirin, Lantus and Pantoprazole was not given 7 times, Buspirone was not given 2 times and Renvela was not given 9 times in the month of June. 2. R2's Face Sheet, undated, documents, a diagnosis of Dementia, Hemiparesis/Hemiplegia following a Cerebral Infarction, Severe Protein-Calorie Malnutrition and Anxiety Disorder. R2's MDS, dated [DATE], documents, R2 had severe cognitive impairment. R2's Care Plan, dated 4/12/23, documents, R2 has chosen to receive hospice care related to failure to thrive. R2's POS, documents the following orders: 6/15/23 - Lorazepam (Ativan) 0.5mg every 12 hours. R2's MAR, documents the following: Lorazepam was not given 2 times in May 2023 and 2 times in June 2023. 145837 Page 3 of 4 145837 06/20/2023 Pittsfield Manor 610 Lowry Street Pittsfield, IL 62363

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 6/20/23 at 9:50 AM, V2, Director of Nurses, stated, if a medication is given or not given, it is documented on the MAR. Stated, if a medication is not given the physician should be notified and a progress note should be recorded. The Medication Administration policy, dated 11/2011, documents all medications must be administered to the resident in the manner and method prescribed by the Physician. 145837 Page 4 of 4