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 (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: 145982 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 145982 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel of Northbrook, The 3300 Milwaukee Ave. Northbrook, IL 60062 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)