Inspection·August 30, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 8/28/2024 at 11:40AM, V2 (Director of Nursing) entered R3's room. R3 was then sitting up on the side of the bed. R3 noted to be confused. R3 was asked if those were her medications sitting on the bedside table and R3 stated I guess they are. V2 stated well (R3) is very slow at taking her medications, it takes a long time, and she won't take her medications until she is ready to take them. V2 was asked if it is their policy to leave medications at bedside and V2 replied no, it isn't. V2 was asked who the medication nurse that was working the hall and she stated V8 (Registered Nurse). V2 then took the medications and left the room. V2 was asked if R3 could make her own decisions, V2 stated No. V2 then took the medications and left the room. On 8/28/2024 at 12:30 PM, V8 (Registered Nurse) was asked if she was the medication nurse for R3 and V8 stated yes, I am. V8 was asked is R3 was confused, V8 stated yes, she is confused most of the time. V8 was asked if she left medications sitting on the bedside table in R3's room, V8 stated (R3) has this funny thing about wanting to keep them in her room, sometimes she refuses to take them until she eats her cereal, so you just have to go along with her because she is confused, I do it all the time. V8 was asked if she leaves medications in R3's room frequently and she stated, yes because she wants us to. V8 was asked if she knows what the facility policy is on medication administration, V8 stated Our policy says we should not do that. We should probably stand there until she takes them. V8 was asked to pull R3's medication cards from the medication cart to identify what medications were in the medicine cup on R3's bedside table. V8 pulled R3's medication cards and identified that the medications were the 12 PM doses Sulfasalazine 500 mg 2 tablets and Carbidopa-Levodopa 25/250 mg one tablet per the pharmacy label on the medication cards. V8 stated yes, these are the medications that were left in R3's room. On 8/28/2024 at 1:15PM, V2 DON (Director of Nursing) stated her expectation is that medications are not left at the bedside unless ordered by the physician. V2 was asked if R2 and R3 had assessments done to be able to self-administer medications, V2 stated I am not sure and I don't know if those type of assessments are in PCC (Point Click Care). V2 stated she recently did education to the nurses on narcotic counts and medications. V2 stated, she can't say she has never seen medications left at bedside, but she hasn't seen any medications at the bedside lately, at lease the last several months except creams and powders. V2 was asked about R2's Nystatin Powder left at bedside. V2 stated (R2) has behaviors and will not let us take the powder. V2 stated R2 is alert and oriented and knows everything going on and she will not let us remove the medicated powder from her room. V2 was asked if she felt Nystatin powder was a prescribed medication, V2 stated yes, it is. V2 was asked if she realized the order was dated for 4/3/2024 and was for 10 days, she stated she would have to check. V2 wasn't sure if the physician was aware R2 was still using the medication. V2 was asked if R2 had an assessment for self-administration of medications and she stated she didn't know because she doesn't know if (name of electronic health record system) has those assessments. Documentation of an assessment to determine R2's ability to self-administer medications were requested at this time for review and none were provided during the survey. The facility policy titled Medication Administration (revision date December 2012) documents a Policy Statement of Medications shall be administered in a safe and timely manner, and as prescribed. The Policy Interpretation and Implementation step #24 documents Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. results were observed and the person administering the drug. The facility policy titled Self-Administration of Medications (revision date December 2016) documents a Policy Statement of Residents have the right to self-administer medications if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145890 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 145890 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Eldorado Rehab & Healthcare 1001 A Jefferson Street Eldorado, IL 62930 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The Policy Interpretation and Implementation documents the following: 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. 3. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications . 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. 9. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. Event ID: Facility ID: 145890 If continuation sheet Page 3 of 3