Health inspection·December 12, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review the facility failed to ensure a resident had his prescribed medication when leaving the facility on a pass home overnight for 1 of 3 residents reviewed for medications in the sample of 3. The findings include: The Nurse's Notes dated 11/28/24 for R1 did not show that he left the building on a pass with his power of attorney. A handwritten note given to R1's POA (Power of Attorney) on 11/28/24 showed, R1 does not have medication strip to provide his mother while out on pass. The note was signed by V4 LPN (Licensed Practical Nurse). The MAR (Medication Administration Record) dated November 2024 for R1 showed on 11/28/24 R1 received his morning medications. R1's evening medications for 11/28/24 were latanoprost opthalmic 0.005%, melatonin 3mg, benztropin mesylate 1mg, depakote 250 mg, depakote 500mg, lorazepam 0.5 mg, pepcid 20 mg, risperidone 0.25 mg. R1's morning medications for 11/29/24 were: aripirazole 5mg, atenolol 50 mg, furosemide 20 mg, spironolactone 50 mg, benztropine mesylat 1 mg, depakote 250 mg, depakote 500 mg, lorazepam 0.5 mg, pepcid 20 mg, risperidone 0.25 mg. R1's MAR dated 11/29/24 had a 1 documented for his morning medications which meant away from the facility with meds. On 12/12/24 at 9:10 AM, V2 DON (Director of Nursing) stated if a resident is going out for a morning appointment medications are given before the resident leaves. V2 stated if the resident is coming back after their appointment then medications would not be sent with the resident. V2 stated the nurse will ask when the resident is returning and if they are going to be out to dinner, shopping etc then the nurse sends the evening medications with the resident. If the resident is going home overnight or for a few days there are tiny envelopes with lines on them to put medications in. They write the name of the medication and when it is due on the envelope. They need to send medications with them. On 12/12/24 at 11:49 AM, V4 LPN stated, R1 was getting ready to leave and his strip of medications were not in the medication cart. V7 (R1's POA - Power of Attorney) was here and it was explained to her. V4 stated V7 was upset and asked why his medications were not there. V4 stated she did not know why. V4 stated she told V6 LPN and she showed her how to order medications. V4 stated they had some of his medications but not all of them. V4 stated she did not know which specific medications went with R1. V4 stated she knew the medication strip containing pills wasn't there. What was available was given is small envelopes that were labeled. V4 stated she did not know which medications were Page 1 of 2 145937 145937 12/12/2024 Forest City Rehab & Nrsg Ctr 321 Arnold Avenue Rockford, IL 61108

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few given. V4 stated she did not have access to the medication machine and she did not look to see if the medications were in there. On 12/12/24 at 11:54 AM, the 2300 hall medication cart had R1's medications inside. The medications that were in a strip (medication in long plastic cover that were individually packaged and labeled) benztropine mesylate 1mg, famotidine 20 mg, risperidone 0.25 mg, aripiprazole 5mg, atenolol 50 mg, and furosemide 20mg. The Care Plan dated 10/30/24 for R1 showed he has a history of exhibiting behaviors of moderate anger related to psychotic symptoms due to his delusions. Administration of psychoactice medications as ordered by physician and monitor adverse side effects R1 has diagnoses that include schizophrenia. R1 has orders for psychotropic medications as ordered. Administartion of psychoactive medications as ordered by physician R1 is on diuretic therapy related to hypertension. Administer medication as ordered. R1 is at risk of developing elevate blood pressure due to essential (primary) hypertension. Medications s ordered per medical doctor. R1 has been diagnosed with geralized anxiety disorder and schizophrenia necessitating the use of psychotropic medication to help manage and alleviate symptoms associated with anxiety and schizophrenia. Carry out medication management regiment as prescribed. R1 is at risk for complications and abdominal discomfort related to astroesophageal reflux disease. Administer medications as ordered per medical doctor. The facilities Guidebook (9/2024) showed, all residents/family/responsible party are expected to sign out at the door when you are leaving. When signing out for an extended period of time with family, you will also be asked to check in/out with your nurse for medications. The Policy & Procedure Administering Medications (1/1/2020) medications shall be administered in physician's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified and the medication is labeled according to accepted standards. 145937 Page 2 of 2