Health inspection·September 14, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate documentation of medications that was administered for 2 of 3 residents (R1,R2) reviewed for medication administration.Findings include: 1.R1's Facility Census documents R1 was admitted to the facility on [DATE] and has the following medical diagnoses; Fibromyalgia, Morbid Obesity, Complex Regional Pain Syndrome, Major Depressive Disorder, HTN, Hypothyroidism, GERD, Anxiety Disorder and Barrett's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score 15 cognitively intact and receives an opioid.R1's Physician Orders Sheet (POS) date documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give 1 tablet by mouth every 8 hours as needed for severe pain.R1's Controlled Drug Receipt Record/Disposition Form dated August 29, 2025, no time given, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.R1's Medication Administration Record (MAR) dated August 29, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.2. R2's Facility Census documents R2 was admitted to the facility on [DATE] and has the following medical diagnoses; Primary Osteoarthritis Right Knee, Type 2 Diabetes, Cellulitis of Left Lower Limb, Non-Pressure Ulcer Right Lower Leg, Ataxia, Difficulty in Walking, Pulmonary Hypertension, Non-ST Elevation Myocardial Infarction, Heart Disease, Venous Insufficiency, Chronic Embolism and Thrombosis of Deep Veins of Lower Extremity. R2's Minimum Data Set (MDS) dated [DATE] documents R2's Brief Interview for Mental Status (BIMS) score 15 cognitively intact and receives an opioid.R2's Physician Orders Sheet (POS) date documents Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams, give 1 tablet by mouth every 4 hours as needed for severe pain. R2's Controlled Drug Receipt Record/Disposition Form dated September 8, 2025, at 5:00am, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.R2's Medication Administration Record (MAR) dated September 8, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams.The Facilities Medication Administration General Guidelines not dated documents: 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 medication do so only after the have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). Documentation (including electronic) 1. The individual who administers the medication dose records the administration on the residents Medication Administration Record (MAR) directly after the medication was given. 3. When as needed (PRN) medications are administered the following documentation is provided: a) Date and time of administration, dose, route of administration and if applicable the injection site. d) signature or initials of person recording administration and signature or initials of person recording effect, if different from the person administering the Page 1 of 2 145911 145911 09/14/2025 Goldwater Care Gibson City 620 East First Street Gibson City, IL 60936

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication. On 9/13/25 at 10:15 AM V4 Licensed Practical Nurse stated that when V4 administers a residents opioid, V4 will open the lock box, obtain the medication and sign out for the medication on the Controlled Drug Receipt Record/Disposition Form. V4 stated after administering the medication, V4 will then sign that the medication was administered in the residents Electronic Health Record (EHR). On 9/13/25 at V1 Administrator confirmed that R1's Controlled Drug Receipt Record/Disposition Form dated August 29th, 2025, no time given, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams and R1's Medication Administration Record (MAR) does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams. V1 also confirmed that R2's Controlled Drug Receipt Record/Disposition Form dated September 8th, 2025, at 5:00am, documents V3 Licensed Practical Nurse signed out for 1 Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams and R2's Medication Administration Record (MAR) dated September 8th, 2025, does not document that V3 Licensed Practical Nurse administered R1's as needed Hydrocodone-Acetaminophen Oral Tablet 5-325 milligrams. V1 stated that V3 should first sign out for the residents narcotic on the Controlled Drug Receipt Record/Disposition Form, and then after administering the medication to the resident, V3 should document that the medication was administered to the resident in the residents Electronic Health Record. 145911 Page 2 of 2