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
(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 2
Event ID:
146008
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
146008
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alden of Waterford
2021 Randi Drive
Aurora, IL 60505
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)
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 .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146008
If continuation sheet
Page 2 of 2
