Health inspection·January 30, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to reorder scheduled medication to ensure availability for a resident and failed to pass medication timely, per physician orders. These failures applied to two (R1, R2) of three residents reviewed for medication administration. Findings include: R2 is a [AGE] year old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: type II DM, HTN, depression, and anxiety. Per R2's physician orders, R2 receives Insulin Lantus Subcutaneous Solution (100 unit/ml) 37 units two times a day scheduled at 8:00AM and 8:00PM. R2 also receives Insulin Lispro Solution (0.5 unit dial) of 17 units three times a day scheduled at 8:00AM, 12:00PM, and 5:00PM. On 1/29/2025 at 10:33AM, V3 (Licensed Practical Nurse) was observed administering medications. V3 said it is 10:33AM and I am still passing my 9:00AM medication. V3 said there are times when we struggle to pass medication in the allotted time which is one hour before and after the scheduled medication time. At 10:45AM, R2 had said there are times where I do not receive my medication till way after the scheduled time. R2 said I receive rapid and long-acting insulin and they are scheduled a certain way to ensure that my blood sugars remain controlled. On 1/18/25, 1/19/25, and 1/23/25, my diabetic medication was given extremely late. I am also concerned about my psych medication when my medication is given late. I can feel myself having increase agitation and becoming irritable when I do not take it timely. Facility Medication Admin Audit Report shows on 1/18/25, R2's Insulin Lispro was scheduled for 5PM and given at 6:41PM and Insulin Lantus was scheduled for 8:00PM and given at 9:45PM. On 1/23/24, R2's Insulin Lispro and Lantus were scheduled for 8:00AM and given at 9:16AM. R2's Insulin Lispro was also scheduled on 1/23/25 for 5:00PM and was given at 8:53PM. At 11:05AM, V4 (Registered Nurse) said it is protocol that we have an hour before and an hour after medication time to adequately pass medications. V4 said I currently have 29 residents and this is very difficult to do. We also use agency nursing staff and there is not way that they are passing medications in the allotted time. Page 1 of 3 145994 145994 01/30/2025 Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few At 11:15AM, V2 (Director of Nursing) was interviewed. V2 said I would expect the nurses to pass the medications within an hour before and an hour after the scheduled time. Two residents, R1 and R2, expressed concern to me last week about their medications being late. V2 said if a resident that has a diagnosis of type II diabetes does not receive their insulin in a timely manner it may cause them to have uncontrolled blood glucose levels and become hyperglycemic. Facility policy titled Medication Administration states in part but not limited to the following: Medications are administered as ordered by the physician in accordance with professional standards of practice. R1 is a [AGE] year-old female admitted to facility on 11/22/2024 with medical diagnosis that includes and not limited to major depressive disorder, anxiety, insomnia, severe obesity, diabetes, hypertension, hyperlipidemia, and gastroesophageal reflux disease. On the (MDS) Minimal data Set assessment of 11/29/2024 section C the BIMS (Brief Interviewed mental status) score was 15/15. On 10/29/2025 at 10:45AM R1 said, I did not take my Pravastatin medication yesterday and I am not taking my medications as ordered per my physician. The PM shift nurse did not have my Pravastatin and had to order it from the pharmacy. On 01/29/2025 at 1:57PM V3 (Licensed Practical Nurse) said, R1 did not receive Pravastatin medication at bedtime. I reorder the Pravastatin medication that was missing. I entered code number 10 under the electronic medication administration record and I charted that medication was missing. On record review of the medication administration for the month of January 2025 the physician medication order reads: Pravastatin Sodium Oral Tablet 40 MG (Pravastatin Sodium) Give 1 tablet by mouth one time a day for hyperlipidemia. On 01/29/2025 at 2:05PM V2 (Director of Nursing) said, I spoke with V3 this morning and I am aware that R1 did not take Pravastatin medication yesterday and medication was reordered. Electronic medication administration record reviewed with V2. R1's medication records showed the Pravastatin medication for 01/27/2025 and 01/28/2025 had code 10. V2 said, R1 did not receive the medication as ordered per physician's orders for both days. V2 said, I expect the nurses to order medication when the stock is running low and when code 10 is used to chart the reason and notify the physician. V2 said, there are two ways that nurses know when to order medication, one is under the electronic medication administration record and the other is when the medication bingo card reaches the last doses. The Bingo medication card has blue or green marking on the last doses ranging from 5 or 8 doses before medication is completely used. There is an emergency box available to be used for emergencies but Pravastatin medication is not one of the medications in the box. On 01/29/2025 at 3:30 PM V2 presented Facility Policy undated, 1- Medication Administration. Which reads in part (but not limited to), 10. Ensure that the six rights of medication administration are followed: a. Right resident., b. Right drug, c. Right dosage, d. Right route, e. Right time f. Right 145994 Page 2 of 3 145994 01/30/2025 Inverness Rehab 1800 W Colonial Parkway Inverness, IL 60067

F 0755 documentation Level of Harm - Minimal harm or potential for actual harm 2-Medication Reordering. Which reads in part (but not limited to), Residents Affected - Few Policy: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 3. Each time a nurse is administering medications and observes medication doses are running low, that nurse will reorder the medication, time permitting. 145994 Page 3 of 3