Inspection·November 4, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to follow their policy to ensure that medications were stored safely and securely. This affected one of three residents (R4) reviewed for medication storage. This failure resulted in one resident (R4) accessing the medication cart. The findings include: On 11/2/24 at 1:28PM V8, Registered Nurse (RN), said I worked on 10/20/24, on the night shift. V8 said I received in report from V11, Licensed Practical Nurse (LPN), I think that was her, that R4 got into the medication cart. V8 said I was told the CNA reported seeing R4 in the cart. V8 said R4 told me she was counting her medication in the cart, I was counting my oxy. V8 said V11 and R4 did not tell me how R4 got in the cart. V8 said I did not report to anyone because V11 told me she reported to the Director of Nursing (DON). V8 said R4's room was outside the nurses station. On 11/2/24 at 1:52PM V2, CNA, said R4 was loud and rude and she would go off. V2 said I never saw R4 in pain. V2 said if R4's medication comes a minute after it is due then she starts saying she is in pain. V2 said I came out of a resident room and R4 was putting the keys back in the binder on the nurses cart. V2 said I saw R4 with the nurse's keys in her hands. V2 said R4 said she was trying to see if she had 2 cards. V2 said the nurse was taking care of another resident in her room. V2 said R4 walked away to the elevator. V2 said I pushed the lock on the cart and took the nurse the keys. V2 said I handed the nurse the keys and told her R4 had the keys. V2 said I didn't know R4 would do that, but she would look at her medication and say there goes my medication. V2 said the cart was unlocked when I walked into R4. On 11/3/24 at 10:35AM V5, Director of Nursing (DON), said on 10/21/24 a manager reported to me the nurse reported that R4 had the key to the medications cart. V5 said I went to speak to V12, because she reported it and I called V8 and V11. V8 told me V11 said the keys were in the drawer. V5 said the CNAs never reported they saw R4 with the keys to the med cart. V5 said V11 told me she left the keys in the drawer during her wound care to another resident. V5 said I told V11 you should have the keys on you. V5 said the expectation is that they notify me. V5 said I don't know if R4 was in the cart. V5 said the expectation is that the medication cart keys are to stay on the nurses at all times. V5 said the medication that could have side effects, antihypertensives, blood thinner, and diabetics medications are stored in the cart. Attempts to reach V11 on 11/2/24 at 2:03PM and 11/3/24 at 10:12AM were unsuccessful. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145942 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 145942 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Landmark of Oak Lawn Rehabilitation and Nursing Ce 9525 South Mayfield Oak Lawn, IL 60453 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)