Health inspection·March 25, 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 interview and record review, the facility failed to administer, store, and dispose of narcotics in accordance with facility policy. This resulted in nursing staff using R2's medication (a discharged resident) for R10 an active resident in the facility. This applies to 2 resident's (R2 and R10) reviewed for narcotic administration and disposal in a sample of 10 residents. On 3/18/25 at 11:27 AM, surveyor noted R2's Controlled Drug Receipt/Record/Disposition Form for Hydrocodone/APAP 5-325 mg (milligram) tablets showed 30 tablets were dispensed on 12/13/24. R2 was given 7 of the 30 tablets between the dates of 12/19/25 and 1/19/25. R2's MAR (Medication Administration Record) shows the 7th tablet was administered to R2 on 1/19/25 at 10AM, which matches the Controlled Drug Form. R2's Face sheet shows he was discharged from the facility on 1/20/25. As of R2's discharge on [DATE], 23 Hydrocodone/APAP 5-325 mg tablets were remaining. R2's Controlled Drug Receipt/Record/Disposition Form shows V2 (DON/Director of Nursing) and V11 (ADON/Assistant Director of Nursing) only counted 21 tablets to destroy on 2/17/25. There was a 2 tablet Hydrocodone/APAP 5-325 mg discrepancy found. On 3/19/25 at 9:39 AM, V1 (Administrator) said she found R2's 2 missing Hydrocodone/APAP tabs were given to another resident, R10, by V14 (RN) and V15 (RN). R10's MAR shows she was given a Hydrocodone/APAP 5-325 mg tablet on 2/13/25 at 1:30 AM by V15 and another Hydrocodone/APAP 5-325 mg tablet on 2/13/25 at 11:00 AM by V14. R10's Controlled Drug Receipt/Record/Disposition Form shows she was given the last Hydrocodone/APAP 5-325 mg tablet of her supply on 2/12/25 at 4AM and did not receive a new supply from pharmacy until 2/14/25. On 3/19/25 at 12:24 PM, V15 (RN) said she used one of R2's Hydrocodone/APAP 5-325 mg tablets for R10 because R10 was in pain and her prescription was not there. V15 said the Hydrocodone/APAP 5-325 mg tablet could have been taken from the emergency floor stock also known as the cubex, but then V15 would have had to call pharmacy. V15 said she knows she wasn't supposed to take any medications from another resident's supply, but R10 was a handful that night. On 3/19/25 at 11:16 AM, V14 said she took one of R2's Hydrocodone/APAP 5-325 mg tabs and gave it to R10 because R10 was having uncontrolled pain and her previous prescription stock had run out. V14 said V15 told her it was authorized by the previous shift to use R2's leftover Hydrocodone/APAP tabs for R10 until her new supply came in. V14 said she didn't think she could get a Hydrocodone/APAP 5-325 mg tab from the cubex to administer to R10 because the pharmacy didn't have an active script and it usually takes over an hour to get the Page 1 of 2 146008 146008 03/25/2025 Alden of Waterford 2021 Randi Drive Aurora, IL 60505

F 0755 code from the pharmacy to get access to the cubex. Level of Harm - Minimal harm or potential for actual harm On 3/19/25 at 12:58 PM, V2 (DON) said all staff were educated they are not to share or borrow narcotics between residents. V2 (DON) said V14 (RN) and V15 (RN) should have accessed Third Eye, an after-hours physician service, to obtain an order for a one time dose of Hydrocodone/APAP 5-325 mg tablet. V2 said after obtaining the order, V14 and V15 would then fax the script to the pharmacy to obtain a code for the cubex. V2 said the whole process would maybe take 1 hour to obtain and give R10 the pain pill. V2 said no nurse has the authority to okay sharing narcotics between residents. Residents Affected - Few The facility's policy titled, Controlled Drug Documentation dated 06/2022 states, A. Purpose: To maintain control and prevent loss and/or diversion of controlled substances .C. Procedure: . 2. Controlled substances must be counted and verified every shift by authorized professionals, .Any discrepancy between the number of controlled drugs on hand and the sheet's balance must be brought to the attention of the Resident Care/Nursing Director (or equivalent) immediately . The facility's policy titled, New Medication Orders dated 06/2022 states, A. Policy/Purpose: Medications are ordered, provided by pharmacy, and initiated on a timely basis .C. Procedure: .5. For facilities using eMARs for which pharmacy entered orders automatically transmit through an interface to the facility's electronic system, the nurse will fax a signed hard copy of physician's orders to the pharmacy. The pharmacy will enter orders based on the faxed documentation and orders will be electronically transmitted immediately after pharmacist verification .8. Initiate medication when received from pharmacy. 9. For facilities that maintain a contingency supply of medications on site, the nurse may take items from the convenience Box or Emergency Box as needed and if available. a. If order is STAT, use medication from Convenience Boxes, if possible . 146008 Page 2 of 2