Health inspection·May 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 ensure proper and safe administration of medications in accordance with facility policy for 2 (R1, R3) of 3 residents reviewed for pharmacy services in the sample of 13. Findings Include: 1. R1's Transfer/Discharge Report documented an admission date of 2/24/2025 and included diagnoses of bradycardia, heart failure, hypertension, type 2 diabetes mellitus with other circulatory complications, weakness and unsteadiness on feet. R1's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicates R1 is cognitively intact. R1's Care Plan had no documentation of self-administration of medications being a goal or focus area for R1. V2 (Adult Protective Specialist) stated, she had direct care with R1 for the past year. V2 stated, R1 had been staying at this facility temporarily until another placement could be arranged. V2 stated, she came to visit R1 on 5/23/2025 around 8:00 am in the morning. V2 stated, when she walked into R1's room, she had been lying in her bed, covered up with blankets and a pillow resting over her head. V2 stated, R1 does prefer to sleep this way. V2 stated, when she entered R1's room, she noticed a medicine cup with medications sitting on R1's assistive device chair cushion. V2 stated, she woke R1 up and R1 stated, she did not know they had left her medications for her this morning, but they normally leave her medications for her because she does not like to get up in the mornings and go to the dining room. On 5/29/2025 at 10:57 AM, R1 stated she does get medication administered to her by the facility. R1 stated, the facility nurses will leave her medication, including eye drops at her bedside without telling her they are there. R1 stated, the nurses say she is too hard to wake up in the mornings. R1 stated V2 did come to visit her on 5/23/2025 sometime after 8:00 AM and woke her up. R1 stated, V2 did observe her medications in a medicine cup sitting on her assistive device cushion. R1 stated her nurse that morning was V6 (Registered Nurse/RN), and she did not wake her up to give her the medications. R1 stated, the facility nurses had been leaving her medication at her bedside more frequently than before. On 5/29/2025 at 12:39 PM, V6 (RN) stated she did work R1's hall on 5/23/2025. V6 stated, she did Page 1 of 3 146021 146021 05/30/2025 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few administer R1's medications to her that morning, signed them off in her electronic health record and does not remember leaving them at her bedside table. V6 stated, R1 is very hard to wake up in the mornings. R1's Medication Administration Record (MAR) documented on 5/23/2025 at 8:00 AM fenofibrate oral tablet 160 MG (milligrams) 1 tablet given by mouth one time a day, ferrous sulfate oral tablet 325 1 tablet by mouth one time a day, furosemide tablet 40 MG 1 tablet by mouth one time a day, glycoLax powder 1 scoop by mouth one time a day, losartan potassium oral tablet 100 MG give 1 tablet by mouth one time a day, protonix oral tablet delayed release 20 MG 1 tablet by mouth one time a day, tamsulosin oral capsule 0.4 MG 1 capsule by mouth one time a day, acetaminophen oral tablet 500 MG 2 tablets by mouth two times a day, azelastine ophthalmic solution 0.05 % instill 1 drop in both eyes two times a day, menthol topical analgesic the pain external gel 4% apply to right shoulder/neck and apply to top of feet and ankle topically two times a day, docusate sodium capsule 100 MG 100 mg by mouth two times a day, apixaban tablet 5MG 1 tablet by mouth two times a day, and pregabalin 50 MG 1 tablet by mouth two times a day, administered by V6 (RN). 2. R3's Transfer/Discharge Report documented an admission date of 2/10/2025 and included diagnoses of alzheimer's disease, chronic kidney disease, major depressive disorder, single episode, severe without psychotic features, and essential hypertension. R3's MDS assessment dated [DATE] documented a BIMS score of 11, which indicates moderate cognitive impairment. R3's Care Plan had no documentation of self-administration of medications being a goal or focus area for R3. On 5/29/2025 at 10:27 AM, R3 stated the nurses in the facility will leave her medications on her bedside table for her to take. R3 stated, she has her morning medications sitting in her room on her bedside table right now waiting for her to take them. R3 stated, V4 (Licensed Practical Nurse/LPN) brought them to her earlier this morning but she was not taking them until after she had her cigarette. On 5/29/2025 at 10:35 AM, R3's medication cup was observed on her bedside table with 4 pills in the cup. 1 pill was blue, 1 pill was green, 1 pill was white and round shaped and 1 pill was white and oval shaped. On 5/29/2025 at 10:37 AM, V4 (LPN) stated he did bring R3 her medications at 8:30 AM this morning, sat them on R3's bedside table and left the room. V4 stated, he is unaware if the facility has a policy that states medications cannot be left at the bedside. R3's Medication Administration Record documented on 5/29/2025 at 8:00 AM, amlopidine 10 mg (milligrams) 1 tablet by mouth one time a day, atorvastatin 40mg 1 tablet given in the morning, losartan potassium 100 mg tablet given in the morning, and sertraline 50 mg tablet administered by V4 (Licensed Practical Nurse/LPN). On 5/29/2025 at 10:39 AM, V3 (Director of Nursing/DON) stated, it is her expectation that medication should be administered as ordered and not left at the bedside table for any resident. V3 stated, if a resident is not able to take the medications at that time, then the nurse should take the medication back to the nurse's cart with them. 146021 Page 2 of 3 146021 05/30/2025 Nature Trail Health and Rehab 1001 South 34th Street Mount Vernon, IL 62864

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/29/2025 at 10:42 AM, V1 (Administrator) stated, it is her expectation that medications are not left at the bedside table for residents and staff should follow the facility's policy and procedures. The facility Medication Administration Policy/Procedure (revised 9/27/22) documented the purpose was To ensure proper administration of oral medications. Under Policy: Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required. Under Responsibility, the policy states It is the responsibility of all licensed nursing staff to safely administer medications to residents. The policy further documents: 5. Identify the individual and explain what is to be done .8. Follow the specific instructions listed for each type of medication to be given. Offer adequate fluids with medications .9. Ensure medication has been swallowed before leaving .a. If medication if refused, chart refusal and notify physician and family/power of attorney. 146021 Page 3 of 3