Health inspection·December 11, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure ordered scheduled medications were administered for one resident (R2). This failure affected one resident out of three residents reviewed for medication administration.Findings include:R2's medical diagnoses include but are not limited to type 2 diabetes mellitus with diabetic autonomic (Poly) neuropathy, heart failure, major depressive disorder, anxiety disorder, presence of cardiac pacemaker.R2's Minimum Data Set, dated [DATE] has a Brief Interview for Mental Status score of 15, indicating R2's cognition is intact.R2's care plan dated 11/15/25 documents in part, I have Diabetes Mellitus diet manage, Insulin dependent.Diabetes medication as ordered by doctor.R2's care plan dated 11/15/25 documents in part, I am at risk for decreased cardiac output R/T (related to): atrial fib, congestive heart failure, hyperlipidemia, hypertension, pacemaker malfunction.Administer medications as orders and observe for side effects and effectiveness.On 12/08/25 at 12:20pm surveyor observed R2 being fed lunch by CNA (Certified Nursing Assistant).On 12/08/25 at 12:42pm R2 stated that she has not received any medication yet. R2 stated that she is a diabetic and has orders to have her blood glucose checked three times a day and is to be given insulin with each meal. R2 stated that she has not had her blood glucose checked all day, nor has she been given any insulin.On 12/08/25 at 12:58pm V3 (Registered Nurse/RN) stated that she had not given R2 any of her morning medications. V3 stated that R2 is a diabetic and R2 should have a blood sugar check twice on her shift. V3 stated that R2 should have had her blood sugar checked at 8am and 11:30am. V3 stated that she had not checked R2's blood sugar or given R2 any insulin. V3 stated that it is important for R2 to have her blood sugar checked because R2 is a diabetic and takes long and short acting insulin.R2's progress note dated 12/08/25 at 3:30pm documents in part, Accucheck (blood glucose) not tested. Notified V16 NP (Nurse Practitioner). Medication not given. Notified V16 NP.R2's medication administration audit record shows that V3 (Registered Nurse/RN) gave R2 insulin injection on 12/08/25 at 3:30pm. R2 physician order dated 11/10/2025 documents in part, Humalog Mix 75/25 KwikPen.Inject 16 units subcutaneously one time a day related to Type 2 diabetes mellitus with diabetic autonomic (Poly) neuropathy 9am.R2's physician order dated 01/08/2025 documents in part, Accu check before insulin, Breakfast, Lunch and Bed time before meals.R2's physician order dated 10/12/2025 documents in part, Lyumjev KwikPen.inject 7 units subcutaneously one time a day related to Type 2 diabetes mellitus with diabetic autonomic (Poly) neuropathy. One time a day with lunch if blood glucose > (greater than) 150.R2's physician order dated 12/05/2025 documents in part, Metoprolol Succinate ER (extended release) oral tablet extended release 24-hour 25 MG (milligram) give 2 tablet by mouth one time a day related to unspecified atrial fibrillation.R2's physician order dated 10/17/2025 documents in part, Furosemide tablet 40 MG give 1 tablet by mouth two times a day related to heart failure.R2's physician order dated 02/04/2025 documents in part, Eliquis oral tablet 5 MG. Give 1 tablet by mouth two times a day for blood thinner.On 12/10/25 at 1:39pm V2 (Director of Nursing) stated that Residents Affected - Few Page 1 of 2 145867 145867 12/11/2025 Alta Rehab at Fairmont 5061 North Pulaski Road Chicago, IL 60630

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication should be given an hour before or an hour after the scheduled medication time. V2 stated that 9am medications can be given up until 10am. V2 stated that she has educated the nursing staff about time sensitive medications. V2 stated that blood pressure medication should be given every twelve hours because it is a time sensitive medication. V2 stated that it is expected that nurses follow doctor's orders. V2 stated that it is not okay for the nurse to not check a resident's blood glucose if the resident has an order for the blood glucose to be checked. V2 stated that R2's insulin should have been administered at the time of R2's meal. V2 stated that if medications are not administered on time, the physician should be notified so that a medication time adjustment could be made. V2 stated that if medications are missed and the times are not adjusted, the resident could become overmedicated.On 12/10/25 at 12:24pm V16 (Nurse Practitioner) stated that she was informed that V3 (RN) did not administer insulin as ordered. V16 stated that V3 did not inform her that R2's morning medications were not given to her. V16 stated that it is expected that all medications are given when they are due. V16 stated that if a medication is not given, it can cause a reverse action. V16 stated that if insulin doses are skipped, it can harm the resident if they are eating 100% of their meals.Facility's undated policy titled Medication Administration General Guidelines documents in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration) .Administration: 9. A schedule of routine dose administration times is established by the facility and utilized on the administration records. 10. Medications are administered within 1 hour before or after scheduled time, except before, with or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. 11. Medication designed to be administered over a 24-hour period are scheduled accordingly. In these cases, an order for twice daily, for example, shall be interpreted as every 12 hours.Documentation (including electronic): 7. If an electronic MAR (medication administration record) system if used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual.Facility's job description titled Registered Nurse (RN) dated 05/02/2017 documents in part, Summary: the RN is responsible for providing direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing to ensure that the highest degree of quality care is maintained at all times. Essential Duties And Responsibilities: Complete and file required recordkeeping forms / charts upon the resident's admission, transfer and / or discharge. Receive and transcribe telephone orders from physicians and record on the Physician's Order form. Chart nurse's notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Prepare and administer medications as ordered by the physician. 145867 Page 2 of 2