Inspection·August 9, 2024

F 0760 Ensure that residents are free from significant medication errors. 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 administer antipsychotic drug, sleeping pill, nicotine patch and pain medication as ordered by the physician. The facility also failed to obtain physician order regarding administration of time-critical scheduled medications to ensure doses were evenly spaced to achieve accurate peak and maintain effectiveness. This applies to 12 of 19 residents (R3, R6, R10 through R19) reviewed for medications in the sample of 19. Residents Affected - Some The findings include: The facility roster showed that R3, R6, R10 through R19 were all residing in the XXX unit of the facility. The roster also showed that census of the XXX unit was 27 residents. The staffing schedule of August 1, 2024, for the night shift nurses showed that V5 (Agency Registered Nurse) was assigned to the XXX unit for the night shift. The schedule time for night shift nurses was from 7:00 P.M. through 7:00 A.M. (12-hour shift). The staffing schedule showed that V5 came late at 11:30 P.M. on August 1,2024 P.M. 1. On August 7, 2024, at 10:00 A.M., R3 was in the main dining room. R3 said that her medications were administered to her late at night. R3 thinks it was given to her past 10:00 P.M., Thursday night of last week (August 1, 2024). R3 said her medications were for her blood pressure, and nerve pain. The POS (Physician Order Sheet) for the month of August 2024 showed that R3, an [AGE] year-old with diagnoses of cerebral infarction, atrial fibrillation, hypertension, pathologic fracture, and AHSD (atherosclerotic heart disease). The POS (Physician Order Sheet) also showed physician order for the following medications: -Eliquis 5 mg. (anticoagulant) 1 tablet 2 times a day for DVT prophylaxis -Gabapentin 300 mg. 1 capsule three times a day for pain. The EMAR (Electronic Medication Administration Record) for August 1st to 7th of 2024 showed that there was no documentation of time when these medications were administered to R3. The EMAR only showed MP A; MP E; MP N. On August 7,2024 at 4:00 P.M., V2 (Director of Nursing) explained that MP A is medication pass afternoon; MP E is medication pass for early morning and or evening, and MP N is medication pass night. V2 explained the early morning is 4:00 A.M through 6:00 A.M.; afternoon is 12:00 Noon through 2:00 P.M.; evening it's confusing I don't know the time since there is already the MP E which is early (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 6 Event ID: 145980 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 145980 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of St Charles, The 850 Dunham Rd St Charles, IL 60174 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)