Health inspection·April 10, 2024

F 0755 medications. Level of Harm - Minimal harm or potential for actual harm On April 10, 2024, at 9:53 AM, R3 stated that the nurse drops off her medications. R3 stated that the nurse does not watch her take her medications because the nurse knows that R3 will take them. R3 state she takes 21 medications in the morning. Residents Affected - Some On April 10, 2024, at 1:35 PM, R8 stated that the nurse drops off her medications. R8 stated the nurse only watches her take her medications sometimes but not all the time. On April 10, 2024, at 1:37 PM, R7 stated that the nurse does not always watch her take her medications. There are times when the nurse just drops off her medications. On April 10, 2024, at 1:43 PM, R9 stated that she is usually at breakfast when the nurse is performing medication pass, so the nurse drops off her medications on her tray in her room. R9 stated she takes her medications when she gets back to her room after she's done eating in the dining room. R1-R3 and R7-R9 did not have a self-administration of medications assessment in their electronic medical records prior to April 10, 2024. On April 10, 2024, at 11:18 AM, V3 LPN (License Practical Nurse) stated I think I have left medications at residents bedside once to help someone somewhere else. V3 said she has not been counseled in regards to leaving medications at residents' bedside. V3 said there was a time when she went to give R1 her medications and R1 was sleeping so V3 left R1's medication at her bedside to prepare medications for another resident. V3 said R1's family (V6) approached V3 and told V3 that R1 has a tendency of trying to put medications in her coke can and not taking them. [R1] has a tendency of pocketing medications. V3 said she wasn't sure if R1 does it all the time. V3 said that R1's family asked V3 to make sure staff watches R1 to make sure she is taking her medication. V3 said it is important to watch residents take their medications so that the medications are effective. V3 said if certain medications are not taken, the blood pressures could go higher, or behaviors could escalate. V6 (R1's Daughter) said that the nurse that worked on Easter Sunday (March 31, 2024-V3) dropped off R1's medications and did not watch her take them. V6 said she brought the medication cup back to the nurse and told her that R1 is throwing the medications out and that staff need to watch R1 take her medications. V6 said the same nurse that worked Easter Sunday (V3) left R1's medications again on April 6, 2024. V6 said she saw R1 put the medications in R1's pop can. On April 10, 2024, at 2:38 PM, V2 DON (Director of Nursing) said R1's family noticed that R1 was not taking her medications. V2 said she put in an order for the nurses to ensure R1 was taking her medications. V2 said she does not recall R1's family bringing up concerns in regard to R1's medications being left at R1's bedside, but V2 said she told R1's family that she was shocked that nurses were leaving medications at bedside. V2 said that nurses should follow up with the resident to ensure they are taking their medications. V2 said, staff can leave the medication on residents' tables and the staff should follow up with the resident in five minutes or so. When V2 was asked if staff are not visually watching the residents taking their medications, then how do staff know that the resident is taking their medications? V2 said That is a good question. V2 said that the staff is trusting the resident to take their medications. The facility Pharmaceutical Services policy revised December 2015 shows, It is the policy of this facility to provide assistance with medication administration as needed or requested. Residents may keep and use prescription and non-prescription medication in their apartment after being evaluated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145887 If continuation sheet Page 2 of 3 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 145887 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Rehab at Wauconda 176 Thomas Court Wauconda, IL 60084 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm for safety in self-administration of medications and must keep their apartment locked at all times when unattended. Residents must keep medications secured from other residents. Over the counter medications, prescription drugs, and biologicals used in the facility must be labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions and the expiration date. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145887 If continuation sheet Page 3 of 3