Health inspection·March 28, 2024

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect and secure the confidential personal medical records of a resident by allowing an unauthorized individual to obtain resident medical records. This failure applied to one of one (R72) residents reviewed for medical records. Residents Affected - Few Findings include: R72 is a cognitively impaired [AGE] year-old resident with diagnoses listed in part, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, occlusion or stenosis of unspecified cerebral artery, vascular dementia, and type II diabetes mellitus. On 03/25/2024 at 12:00pm, V4 (Family Member) said about two months ago, the facility gave confidential records belonging to R72 to an unauthorized family relative. V4 further said the relative posed as V4 and convinced facility staff to hand over the personal medical documents. On 03/27/2024 at 1:45pm, V3 (Assistant Administrator) said on 02/03/2024, a person impersonated V4 at the facility and an agency nurse gave R72's medical information, specifically, R72's progress notes and care plan, to him. V3 said there were family dynamics within R72's family. V3 said after the breach occurred, R72's power of attorney and V4 were notified, and the family member that posed as V4 was banned from the facility. V3 said the agency nurse that gave R72's medical information to the unauthorized family member failed to fill out a medical release form needed to request the information, and added that it happened on a weekend when the weekend manager was on duty. V3 said the assistant director of nursing was notified, as well as the responsible nurse's agency, and in-service education was provided to staff. V3 lastly said attempts were made to try to get the released medical documents back from the relative but he did not return them. Facility provided a Concern Response Form dated 02/03/2024 and filled out by V3, which read: reported that his cousin pretended to be him and requested medical records from the nurse on duty. The form further states the assistant director of nursing told the administration team who told V4 they would, follow compliance process and submit breach to OCR (Office for Civil Rights) and AG (Attorney General). The facility's, Medical Records Request and Access policy dated 10/17/2018, states in part, the resident or legal representative of the resident will be allowed access to inspect resident's medical records within 24 hours of a valid oral or written request to the Administrator excluding weekends or holidays. Page 1 of 3 145931 145931 03/28/2024 Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record reviews, the facility failed to administer medications as ordered; and failed to follow policy and manufacturer's instructions for use in the administration of inhalers. There were 25 opportunities with four errors resulting in a 16% medication error rate. The errors involved two (R30 and R138) of nine residents in the sample of 74 reviewed for medication administration. Residents Affected - Few Findings include: On 03/25/24 at 4:45 PM, V8 (Licensed Practical Nurse, LPN) was observed preparing medications of R30. According to POS (Physician Order Sheet) dated 06/08/22, R30 has an order for Nabumetone tablet 500mg (milligrams) give 0.5 tablet by mouth two times a day. Also, POS dated 03/24/24 documented: Tylenol oral capsule 325mg give 2 tablets by mouth every 4 hours as needed for pain AND give 2 tablets by mouth two times a day for arthritis on shoulder. During medication pass observation, V8 asked R30 if she was experiencing pain. R30 stated no. V8 did not give Tylenol and Nabumetone. V8 was asked why she did not administer the two medications on R30. V8 stated, She is not in pain. I am not sure if I should give it or not. I am not familiar with Nabumetone so I have to ask the doctor. At 5:10 PM, V9 (Registered Nurse, RN) was observed preparing R138's inhalers. R138 has the following orders: POS dated 07/29/21 documented: Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) mcg/act (microgram per actuation) 2 puffs inhale orally two times a day POS dated POS 09/14/22: Advair Diskus Aerosol Powder Breath Activated 250-50 mcg/dose (microgram per dose) 1 puff inhale orally two times a day During medication pass, V9 stated that R138 knows how to administer the inhalers with her supervision. V9 took the Albuterol, did shake it and gave it to R138. R138 administered himself with 2 consecutive puffs. When R138 finished giving himself the puffs, he opened his mouth and a white smoke was observed coming out. Subsequently, V9 took the Advair Diskus, did shake it and handed it to R138. R138 administered himself with 2 consecutive puffs. Then, he took a cup of water, took it all in, did not gurgle. There were no instructions provided on R138 prior to administering the inhalers. Also, R138 gave himself two puffs of Advair when the order stated one puff only. Per manufacturer's guidelines, the following instructions were documented in part but not limited to the following: Instructions for Use Ventolin HFA (Albuterol Sulfate Inhalation Aerosol for Oral Inhalation Use): Step 5 - After the spray comes out, take your finger off the metal canister. After you have breathed in all the way, take the inhaler out of your mouth and close your mouth. Step 6 - Hold your breath for about 10 seconds, or for as long as is comfortable. Breathe out slowly as long as you can. If your healthcare provider has told you to use more sprays, wait 1 minute and shake the inhaler again. Instructions for Use Advair Diskus: 145931 Page 2 of 3 145931 03/28/2024 Warren Barr Lieberman 9700 Gross Point Road Skokie, IL 60076

F 0759 Step 5 - Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow. Level of Harm - Minimal harm or potential for actual harm On 03/27/24 at 10:28 AM, V2 (Director of Nursing) was interviewed regarding medication administration on R30 and R138. V2 replied, The Nabumetone and Tylenol should be given to R30 because it is a standing order. For R138's inhalers, we have to follow the manufacturer's guidelines and policy in administering inhalers. Residents Affected - Few Facility's policy titled, Medication Pass dated 07/28/23 documented in part but not limited to the following: Policy Statement: It is the policy of the facility to adhere to all Federal and State regulations with medication pass procedures. Procedures: 3. Inhalers b. Shake inhaler first. Powder inhaler such as Advair does not need to be shaken first. c. Rinse mouth with water afterwards. Some inhalers do not need to be rinsed with water after administration. d. If there are 2 different inhalers to be given at the same time, make sure there is at least 30-60 seconds interval in between inhalers. Facility's policy titled Physician Orders dated 07/28/23 stated in part but not limited to the following: Policy Statement: It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. 145931 Page 3 of 3