Health inspection·April 11, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow physician's orders and failed to administer medication in accordance with acceptable clinical practice for 9 (R1, R5, R7, R31, R43, R54, R78, R95, R99) of 9 residents reviewed for medication administration. Residents Affected - Some Findings include: On 4/9/24 at 9:54AM V11 LPN (Licensed Practical Nurse) was observed completing 9:00AM medication administration. After holding one tablet metoprolol 25mg (milligrams) from R45, V11 returned to the medication cart, and placed the tablet back in the medication blister pack with unclean hands. V11 said, it was okay to return the medication because it did not fall on the floor. Surveyor observed V11 touch the medication with V11's bare hands and brought into the resident's room. The medication fell out of the medication cup and onto the tray. At the conclusion of the observation V11 said, although they had passed medications to all their residents, they did not sign out all the medications as given on the MAR (Medication Administration Record). Surveyor observed on the Electronic Health Record, that several resident cards were red indicating overdue administration/documentation. V11 said, all medications for the morning shift needed to be signed out for the following residents: R95, R78, R31, R43, R1, R5, R7, R99 and R54. V11 said, sometimes they sign out the medications as they give them, but most of the time, they finish the mediation pass and sign out the medications while sitting at the nurse's station and usually the nurse completes documentation by 9:50AM before turning red. On 4/9/24 at 3:00PM V2 (Director of Nursing) said, it is the expectation and according to policy that medications are documented and signed out as soon as they are given to the resident. Once medications are removed from packaging, they should be discarded if not administered. Facility Policy titled Medication Administration (Pharmacy) revised 10/2014 states in part: B. Administration 2.) Medications are administered in accordance with written orders of the prescriber. 18.) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, an action is taken as appropriate. D. Documentation (including electronic) 1.) The individual who administers the mediation dose records the administration on the resident's MAR directly after the mediation is given. At the enc of each mediation ass, the person Page 1 of 6 145982 145982 04/11/2024 Citadel of Northbrook, The 3300 Milwaukee Ave. Northbrook, IL 60062

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medication. 6.) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage administration is [initialed and circled]. An explanatory note is entered on the reverse side of the record. If [consecutive doses] of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response. If an electronic MAR system is used, specific procedures required for resident identification, identifying medications due at specific times, and documentation of administration, refusal, holding of doses, and dosing parameters such as vital signs and lab values are described in the system's user manual. These procedures should be followed and may differ slightly from the procedures for using paper MARs. On 04/09/24 at 11:40AM, R99 was observed in her room, awake and alert. R99 stated she had a headache, she does not get her medication on time, and she has noticed small flies in her room for a while now. Surveyor observed a medication cup with 4 large white pills, one oval and the other three round on resident's bedside table. R99 said she does not know what the medications are, not sure how long it has been there, but she does not think that it is from this morning, it might be from the previous day. On 04/08/24 at 11:50AM, V3 (Unit Manager) was called to the room and shown the medications in the cup. V3 said she does not think the medications are from this morning, but probably from yesterday, because she did not pass morning medication for the resident today, another nurse did but she went home for an emergency. V3 identified the medications as Sul Carafate 1gm three times a day, Magnesium 1 tablet daily, and 2 tablets of Simethicone every 8 hours. V3 was asked if it is their normal practice to leave medication at the bedside. V3 said, No, nurses are not supposed to leave medications at the bedside. 145982 Page 2 of 6 145982 04/11/2024 Citadel of Northbrook, The 3300 Milwaukee Ave. Northbrook, IL 60062

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, Interview and Record Review, the facility failed to have a five percent (5%) or less medication error rate for one (R45) of one resident. There were 13 medication errors out of 34 medication opportunities, resulting in a 38.24% medication error rate. Residents Affected - Few Findings include: On 04/09/24 at 09:14 AM V11 LPN (Licensed Practical Nurse) was observed administering 9:00AM medications to R45. When administering to R45, V11 said R45 takes medications whole, individually and in applesauce. R45 said R45 only wanted one pill prior to V11 administering, which V11 acknowledged. V11 administered medications by spoon and two pills were observed in the applesauce. R45 spit one small yellow pill out and nurse gathered with tissue, not questioning or re-offering. After observing administration, V11 was about to throw out the tissue when surveyor asked to identify the tablet. V11 said V11 didn't know what the tablet was, but then recognized it as digoxin against the medication card. V11 said this is a heart medication. Administered medications for R45 were reconciled against the current (April 2024) Medication Administration Records (MAR). Errors noted included: Not Given: Digoxin Oral Tablet 125 MCG (Digoxin) Give 0.5 tablet by mouth one time a day related to heart failure. Physician Order: Fish Oil Capsule 1200 MG (Omega-3 Fatty Acids) Give 1 capsule by mouth one time a day for supplement. Given: Fish Oil 1000mg (milligrams). Omitted Medications: Loratadine Tablet 10 MG Give 1 tablet by mouth one time a day for allergy (V11 did not offer or provide this medication). Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril two times a day for Nasal congestion (V11 did not offer or provide this medication). Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical)) Apply to Anterior ribs topically four times a day for pain apply 2 grams (V11 did not offer or provide this medication). On 04/09/24 at 9:36AM V11 was observed preparing and administering medications to R23. Errors included: Physician Order reads: Cholecalciferol (vitamin D3) Tablet 1000 UNIT Give 2 tablet by mouth one time a day for supplement. V11 gave vitamin B12 100mcg 1 tab. Physician Order reads: Docusate Sodium Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth every 12 hours for Constipation; and Sennosides Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth two times a day for Constipation. V11 gave Senna Plus (Docusate 50mg, Senna 8.6mg) 1 tab. Physician Order reads: Metoprolol Tartrate Oral Tablet 25mg. Give 1 tablet by mouth two times a day 145982 Page 3 of 6 145982 04/11/2024 Citadel of Northbrook, The 3300 Milwaukee Ave. Northbrook, IL 60062

F 0759 for hypertension (no parameters noted). V11 held the medication without notifying the physician for a blood pressure of 113/69 and pulse of 91 beats per minute (as observed during vital signs taken at bedside). Level of Harm - Minimal harm or potential for actual harm Omitted 9:00AM Medications: Residents Affected - Few Lexapro Tablet 20 MG (Escitalopram Oxalate) Give 20 mg by mouth one time a day for depression/ anxiety. Spiriva HandiHaler Inhalation Capsule 18 MCG (Tiotropium Bromide Monohydrate) 1 capsule inhale orally one time a day for COPD/ 1 cap inhale once per day. Inhale the contents of 1 capsule daily. 2 puffs = 1 capsule. Artificial Tears Solution 1 % (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes two times a day for 1 drop in both eyes BID. Keppra Oral Tablet 750 MG (Levetiracetam) Give 750 mg by mouth two times a day for Seizure disorder. NasoGel Nasal Gel (Saline) 1 application in both nostrils two times a day for dryness in nostrils Facility Policy titled Medication Administration (Pharmacy) revised 10/2014 states in part: A. 4). Five Rights- Right resident, right drug, right dose, right route ad right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dosed is prepared and the mediation put away. A. Check #1: Select the Medication-label, container and contents are checked for integrity, and compared against the mediation administration record (MAR) by reviewing the 5 Rights. B. Check #2: Prepare the dose-the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. C. Check #3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights. 5. Prior to administration, the mediation and dosage schedule on the resident's medication administration record (MAR) are compared with the mediation label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions the physician's orders are checked for the correct dosage schedule. 145982 Page 4 of 6 145982 04/11/2024 Citadel of Northbrook, The 3300 Milwaukee Ave. Northbrook, IL 60062

F 0759 B. Administration Level of Harm - Minimal harm or potential for actual harm 2. Medications are administered in accordance with written orders of the prescriber. Residents Affected - Few 145982 Page 5 of 6 145982 04/11/2024 Citadel of Northbrook, The 3300 Milwaukee Ave. Northbrook, IL 60062

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to follow hand hygiene procedures during medication administration for two (R23 and R45) residents reviewed for infection control. Residents Affected - Few Findings include: On 4/9/24 at 9:14AM, V11 LPN (Licensed Practical Nurse) was observed preparing and administering medications. During this observation, V11 did not perform hand hygiene at the beginning of the observation. Surveyor observed V11 remove tablets from medication blister cards popping the medications in V11's hand and placed them in a medication cups. As V11 moved across the cart, touching cards and common surfaces, V11 did not stop to perform hand hygiene. V11 continued this practice for two different residents R23 and R45. Facility Policy titled Medication Administration (Pharmacy) revised 10/2014 states in part: Preparation: 2. Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident, and before and after administration of ophthalmic, topical, vaginal, rectal, and parenteral preparations and mediations given via enteral tubes. Examination gloves are worn when necessary. Hand sanitization is done with an approved sanitizer between handwashing, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface). Sanitization can be done at regular intervals during the medication pass such as after each room, again assuming handwashing is not indicated. Sanitization is not a substitute for proper handwashing, and washing should be done if there is any question. 145982 Page 6 of 6