Health inspection·June 30, 2023

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to protect 4 residents (R1, R2, R3, R5) from misappropriation of narcotic medications. This applies to 4 of 5 residents reviewed for misappropriation in the sample of 11. Residents Affected - Some The findings include: 1) R1's physician's orders dated 5/22/23 showed, Hydrocodone-Acetaminophen 10-325mg 1 tablet every 4 hours as needed for pain. R1's-controlled drug receipt/record/disposition form showed on 6/10/23 R1 had 4 Hydrocodone tabs remaining. On 6/11/23, R1 had 3 Hydrocodone tabs remaining in his medication card with no documentation of R1 receiving any Hydrocodone on 6/11/23. The facility was unable to account for 1 of R1's Hydrocodone tablets. 2) R2's physician's orders dated 6/7/23 showed, Hydrocodone-Acetaminophen 5-325mg 1 tablet every 4 hours as needed for pain. R2's-controlled drug receipt/record/disposition form showed on 6/10/23 R2 had 20 Hydrocodone tabs remaining. On 6/11/23, R2 had 19 Hydrocodone tabs remaining in her medication card with no documentation of R2 receiving any Hydrocodone on 6/11/23. The facility was unable to account for 1 of R2's Hydrocodone tablets. 3) R3's physician's orders dated 4/29/23 showed, Hydrocodone-Acetaminophen 10-325mg 1 tablet every 6 hours as needed. R3's-controlled drug receipt/record/disposition form showed on 6/8/23 R3 had 15 Hydrocodone tabs remaining. On 6/11/23, R3 had 13 tabs remaining in her medication card with no documentation of R3 receiving any Hydrocodone on 6/11/23. The facility was unable to account for 2 of R3's Hydrocodone tablets. 4) R5's physician's orders dated 5/15/23 showed, Oxycodone 5mg take 1/2 tablet every 4 hours as needed for pain. R5's-controlled drug receipt/record/disposition form showed on 6/11/23 R5 had 25 Oxycodone tabs remaining. On 6/11/23, R5 had 24 Oxycodone tabs remaining in her medication card with no documentation Page 1 of 5 145917 145917 06/30/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0602 of R5 receiving a second dose of Oxycodone on 6/11/23. Level of Harm - Minimal harm or potential for actual harm The facility was unable to account for 1 of R5's Oxycodone tabs. Residents Affected - Some On 6/29/23 at 11:37AM, V1 (Administrator) and V2 (Director of Nursing) stated V3 (Assistant Director of Nursing-ADON) spoke to V4 (Registered Nurse) about an hour and a half before shift change and she was fine. V8 (Licensed Practical Nurse-LPN) notified V3 that V4 wasn't acting right, and they couldn't complete narcotic count so V3 took V4 to the human resources office and they called me (V1) and I came right in. We notified the local police department and I thought she would get drug tested at the emergency room but since she was not going to the emergency room, I drug tested her. Her drug test showed positive for opiates. She was very calm and sleepy and could hardly stay awake during this whole process. The police interviewed her while she was still at the facility and interviewed her a few days later and she couldn't recall the events of that day. The aides on that day were agency and the other one was new so they didn't know her and couldn't have been able to tell if she wasn't acting right. A narcotic count was completed with V9 and V3 so that the count could be corrected. We never did find any of the missing medications in the facility, so we are assuming that V4 ingested all of them during her shift that day. On 6/29/23 at 12:35PM, V9 (LPN) stated he came to work at approximately 3:00PM on 6/11/23 and began counting narcotics with V4 (Registered Nurse). V9 stated the count started off wrong and he thought maybe it was just a mistake and then when they kept counting the narcotics, the counts remained off for several residents and V4 appeared impaired, slurring her words, and couldn't give an explanation as to why the medication count was incorrect. V9 stated V4 did not sign out on any narcotics for several residents on their narcotic count form and on the electronic medication administration record. V9 then stated he alerted V3 (ADON) who was the manager on duty that day and she came and removed V4 from the nursing cart and took her to the human resources office. V9 and V3 then corrected the narcotic count so that V9 could begin passing evening medications to residents. On 6/29/23 at 12:44PM, V6 (Local Police Detective) stated an officer came to the facility on 6/11/23 at approximately 3:35pm for reports of an intoxicated nurse and narcotic counts were off. (V3-ADON) reported she suspected (V4-Registered Nurse-RN) had ingested medications and was intoxicated. (V9 LPN) reported that (V4-RN) was not acting right, appeared under the influence, and was swaying at the nurse's cart. (V4) stated she did not take any medications from the medication cart, but the officer stated (V4's) pupils were constricted, she had slow speech and slow reactions. Another officer checked (V4) for medications and her vehicle as well as the staff lounge and there were no medications present. (V4) then consented to a toxicology test and it tested positive for opiates .I met with her a few days later and she told me that she was intoxicated while she was working all day and doesn't recall anything from the entire day until the police showed up at the facility. The facility's policy titled, Abuse Prevention Program (Facility) Policy and Procedure dated 7/1/22 showed, .IV. Establishing a Resident Sensitive Environment: This facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and resident secure environment . The facility's policy titled, Controlled Drug Policy and Procedure dated 1/1/13 showed, The narcotic count and inventory- 2. The inventory of the controlled drugs must be recorded on the narcotic records and signed for accuracy of count. 145917 Page 2 of 5 145917 06/30/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report an allegation of theft to Illinois Department of Public Health (IDPH) within the required timeframes. Residents Affected - Few The findings include: The Illinois Department of Public Health Long Term Care Facility Serious Injury Incident and Communicable Disease Report dated 6/26/23 showed, During the change of shift on June 11, 2023, at approximately 2:55PM it was observed that the narcotic count was off on 5 residents-controlled drug receipt/record/disposition form. A total of 7 narcotics were missing during the change of shift, nurse to nurse handoff . The facility did not submit an initial report to IDPH and did not submit a final report to IDPH within 5 business days. The facility submitted a final report to IDPH on 6/26/23. (15 days after the incident occurred) On 6/29/23 at 11:07AM, V1 (Administrator) stated, I had no idea that I had to report this to IDPH. I wasn't going to report it either until the police came back to the facility on 6/26/23 and told me it was possibly neglect. Once I started filling out the serious injury incident report, I saw that there was a box to check by medication diversion and I immediately knew I didn't report it when I was supposed to. The facility's policy titled, Abuse Prevention Program (facility) Policy and Procedure dated 7/1/22 showed, VIII. External Reporting .this report shall be made immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or resulted in serious bodily injury; or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury .2. Five-day Final Investigation Report. Within 5 working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation, will be sent to the Department of Public Health . 145917 Page 3 of 5 145917 06/30/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to document administration of narcotic medications to ensure accurate reconciliation for 4 of 5 residents (R1, R2, R3, R5) reviewed for pharmacy services in the sample of 11. The findings include: 1) R1's physician's orders dated 5/22/23 showed, Hydrocodone-Acetaminophen 10-325mg 1 tablet every 4 hours as needed for pain. R1's Controlled Drug Receipt/Record/Disposition Form showed R1 received a dose of Hydrocodone on 6/1/23, 6/2/23, 6/5/23, and 6/9/23. R1's MAR for June 2023 contained no documentation of R1 receiving Hydrocodone on these dates. R1's June 2023 MAR showed R1 received a dose of Norco on 6/10/23; however, there was no documentation on R1's Controlled Drug Record form. 2) R2's physician's orders dated 6/7/23 showed, Hydrocodone-Acetaminophen 5-325mg 1 tablet every 4 hours as needed for pain. R2's Controlled Drug Receipt/Record/Disposition Form showed R2 received a dose of Hydrocodone on 6/7/23 and one dose daily from 6/13/23-6/16/23. R2's Medication Administration Record (MAR) for June 2023 contained no documentation of R2 receiving Hydrocodone on these dates. 4) R5's physician's orders dated 5/15/23 showed, Oxycodone 5mg take 1/2 tablet every 4 hours as needed for pain. R5's Controlled Drug Receipt/Record/Disposition Form showed R5 received one dose of Oxycodone on 6/12/23 and 6/14/23. R5's June 2023 MAR showed no documentation of R5 receiving Oxycodone on these dates. On 6/29/23 at 9:48AM, V7 (Agency Licensed Practical Nurse) stated anytime a narcotic is administered to a resident the nurse would then sign that narcotic out in the resident's Controlled Drug Form and on the MAR. V7 stated there would be no reason why a nurse would not sign the narcotic out in both places. V7 stated if a medication is not signed out on the MAR, then a resident could get a dose of narcotic medication before the time it is scheduled for because the system will not know that the resident already received the medication. On 6/29/23 at 12:10PM, V2 (Director of Nursing) stated that all narcotic medications are signed off on the residents Controlled Drug Form and the resident's MAR. V2 stated this is unacceptable for nurse's not to be signing it out in both places and not doing so could lead to a medication error and potential overdose of narcotics. We also use the documentation if there is a discrepancy during the shift-to-shift count of narcotics. If a nurse forgets to document in either place, then we can check the MAR or Controlled Form to see if they charted it there then that would resolve the discrepancy. The facility's policy titled, Controlled Drug Policy and Procedure dated 1/1/13 showed, Objective: To provide physical facilities and method of operation for the administration and control of narcotics, depressants, and stimulant drugs, which will meet the requirement of State and Federal narcotic enforcement agencies .The Narcotic Count and Inventory: 2. The inventory of the controlled drugs 145917 Page 4 of 5 145917 06/30/2023 Fair Oaks Health Care Center 471 Terra Cotta Avenue Crystal Lake, IL 60014

F 0755 must be recorded on the narcotic records and signed for accuracy of count. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 145917 Page 5 of 5