Health inspection·March 4, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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, observation, and record review the facility failed to administer medications per physician's orders for 4 of 4 residents (R1, R2, R3, R5) reviewed for pharmacy services in the sample of 15. Findings include: 1. R1's Face Sheet undated documents R1's admitting diagnoses as Paraplegia, Secondary Malignant Neoplasm of Bone, Unspecified Severe Protein-Calorie Malnutrition, Malignant Neoplasm of Prostate and Chronic Pain Syndrome. R1's Physician Order Summary (POS) dated February 2025 documents medications as Fentanyl Transdermal Patch 72 hours, 25 micrograms (mcg) /hr (Pain), Thiamine 100 milligrams (mg) Daily (low B1), Magnesium 400 milligrams Daily (supplement), Vitamin B6 Daily (supplement), Vitamin K2 100 mcg Daily (supplement), Vitamin B12 500 mcg Daily (vitamin), Oxycodone 10 mg every 6 hours as needed (pain), Potassium 10 Milliequivalent Daily (diuretic use), Senna Plus 50-8.6 mg twice a day (constipation), Lasix 20 mg Daily (edema), Eliquis 5 mg twice day (Deep Vein Thrombosis), Vitamin D3 50000 Units once a week (Vitamin D deficiency), Juven Daily (wound healing) and Baclofen 10 mg Daily (muscle spasms). R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, rates pain 2/10, receives scheduled, PRN (as needed) pain medications and non-medication interventions, experiences pain occasionally and pain interferes with daily activities occasionally. R1's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents several of R1's medications were administered 2 hours or more past scheduled times. On 2/6/2025 10 milligrams Oxycodone was scheduled 12:00 PM but was administered at 4:06 PM. On 2/7/2025 20 milligrams Lasix, 10 Milliequivalent Potassium, 100 Milligram Thiamine, 50000 Units Vitamin D3, 500 Micrograms Vitamin B12, 5 Milligram Eliquis, 400 Milligram (mg) Magnesium, and 50 Milligram (mg), Vitamin B6 was scheduled for 8:00 AM was administered at 10:03 AM. On 2/7/2025 10 Milligram (mg) Oxycodone was scheduled for 12:00 PM was administered at 2:37 PM. On 2/11/2025 Fentanyl Transdermal Patch 72 hour 25 Micrograms (mcg/hr.) was scheduled for 8:00 PM was administered 10:36 PM. On 2/12/2025 500 Micrograms (mcg) Vitamin B12, 100 Milligram (mg) Thiamine, Multivitamin with Minerals, 10 Micrograms (mEq) Potassium, 20 Milligram (mg) Lasix 50 Milligram (mg) Vitamin B6, 5 Milligram (mg) Eliquis was scheduled for 8:00 AM but was administered at 11:11 AM. On 2/12/202 100 Microgram (mcg) Vitamin K2 and 400 Milligram (mg) Magnesium was scheduled for 9:00 AM but was administered at 11:11 AM. On 2/22/2025 400 Milligram (mg) Magnesium, 100 Microgram (mcg) Vitamin K2, 500 Microgram (mcg) Vitamin B12, 100 Milligram (mg) Thiamine, 10 Milliequivalent (mEq) Potassium and 20 Milligram (mg) Lasix was scheduled for 8:00 AM but was administered at 11:19 AM. On 2/25/2025 Juven for wound healing was scheduled for 8:00 AM Page 1 of 5 146051 146051 03/04/2025 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0755 but was not administered until 2:48 PM. Level of Harm - Minimal harm or potential for actual harm On 2/28/25 at 12:07 PM V8, Licensed Practical Nurse, LPN, stated R1's medications are late because sometimes he (R1) requests them to be given later. R1 was either talking on the telephone, outside smoking or taking a shower. She had not notified the doctor that the meds were being administered later than the scheduled time. Residents Affected - Some R1's Nurse Progress notes dated 2/4/25 at 9:19 AM documents Late Entry: Resident yelled at this nurse due to was late coming in with medication. Tried to explain to resident that it was a few minutes, and we had an emergency. He stated, what was the emergency? Explained to resident that we could not let resident know other residents' information. Resident yelled at this nurse and said, I just want you to do your damn job! Explained to resident that I was and unfortunately things happen. Resident continued to yell at this nurse and stated he was reporting me. This nurse left his room. R1's Nurse Progress Notes dated 2/12/25 at 11:56 AM documents Med taken to resident at 7am and didn't want them until he ate his breakfast. I approached him at 8am and he did take them then as I stood there and watched him, I did not get meds signed off until later due to an emergency at that time. On 2/27/25 at 12:00 PM R1 stated he does argue with them about his medication because it's always an ordeal. He knows what medications he takes and when they short him on his medications. The vitamins are important to his well-being and his dealing with the cancer. Rather than saying they made a mistake the staff want to argue with him. On 2/27/2025 at 3:45 PM, V6 LPN stated she had not had to call the doctor because her meds are not late. R1 has accused her of messing with his meds and asked that she not be assigned to him anymore. 2. R2's Face Sheet undated documents R2's admitting diagnoses Disruption of External Operation (surgical) wound, not elsewhere, Classified, subsequent encounter, Acquired absence of other Genital Organ (s), Unilateral Primary Osteoarthritis, left hip, Lymphedema, not elsewhere classified, Neurocognitive Disorder with Lewy Bodies and Secondary Parkinson, unspecified. R2's Physician Order Summary (POS) dated February 2025 documents medications as 24 Microgram (mcg) Amitiza twice a day (Irritable Bowel Syndrome), 15 Milliliters (ml) Mouth/Throat solution 12%, 25-100 Milligram (mg) Carbidopa-Levodopa twice a day (Hypothyroidism), 850 Milligram (mg) Metformin (Type 2 Diabetes Mellitus), 500 Milligram (mg) Levetiracetam (tremors), 2.5 Milligram (mg) Eliquis (atrial fibrillation), 25 Milligram (mg) Metoprolol twice a day (primary hypertension) and Refresh Plus Ophthalmic Solution 0.5% (dry eyes). R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact and has medical conditions of coronary heart disease, hypertension, neurogenic bladder, diabetes mellitus, hyperlipidemia, Non-Alzheimer dementia. R2's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents the following R2's medications were administered 2 hours or more past scheduled times: On 2/4/2025 40 Milligram (mg) Furosemide, 500 Microgram (mcg) Cyanocobalamin, Peridex Mouth/Throat Solution 0.12%, 25-100 Milligram (mg) Carbidopa-Levodopa twice a day, 850 Milligram (mg) Metformin, 500 Milligram (mg) Levetiracetam, 2.5 Milligram (mg) Eliquis twice a day, 25 Milligram (mg) Metoprolol twice a day and Refresh Plus Opthalmic Solution 0.5 %, 40 Milligram (mg) Lisinopril, 40 Milligram (mg) Protonix, 400 146051 Page 2 of 5 146051 03/04/2025 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Microgram (mcg) Folic Acid were scheduled for 7:45 AM but were administered at 11:59 AM; on 2/4/2025 600 Milligram (mg) Guaifenesin ER, 10 Milliequivalent (mEq) Potassium Chloride Extended Release, 10 Milligram (mg) Zyrtec, Aspirin Enteric Coated (EC) Low Strength and 10 Milligram (mg) Amlodipine was scheduled for 8:00 AM but was administered at 11:59 AM; on 2/4/2025 Peridex Mouth/Throat Solution 0.12%, 25-100 Milligrams (mg) Carbidopa-Levodopa twice a day, 850 Milligram (mg) Metformin, 500 Milligram (mg) Levetiracetam, 2.5 Milligram (mg) Eliquis twice a day, 25 Milligram (mg) Metoprolol twice a day and Refresh Plus Opthalmic Solution 0.5 % were scheduled for 5:00 PM but was administered at 9:05 PM; on 2/18/2025 600 Milligram (mg) Guaifenesin Extended Release, 40 Milligram (mg) Atorvastatin were scheduled for 8:00 PM but were administered at 10:02 PM; on 2/21/2025 Peridex Mouth/Throat Solution 0.12%, 25-100 Milligram (mg) Carbidopa-Levodopa twice a day, 850 Milligram (mg) Metformin, 500 Milligram (mg) Levetiracetam, 2.5 Milligram (mg) Eliquis twice a day, 25 Milligram (mg) Metoprolol twice a day and Refresh Plus Opthalmic Solution 0.5 % were scheduled for 5:00 PM but was administered at 7:52 PM. 3. R3's Face Sheet undated documents R3's admitting diagnoses Non-pressure Chronic Ulcer of Other Part of Left Foot with Unspecified Severity, Diabetes Mellitus due to Underlying Condition with Foot Ulcer, Vascular Dementia, Unspecified Severity, with other Behavioral Disturbances, Encephalopathy, Unspecified, Hyperlipidemia, Unspecified. R3's Physician Order Summary (POS) dated February 2025 documents R3's medications as 40 Unit Lantus (Diabetes), 500 Milligram (mg) Metformin (Diabetes), 5 Milligram (mg) Lisinopril (hypertension), 50 Milligram (mg) Diclofenac (arthritis), 100 Milligram (mg) Gabapentin (pain), 325 Milligram (mg) Ferrous Sulfate (65 Fe), 81 Milligram (mg) Aspirin (supplement), 40 Milligram (mg) Omeprazole (Gastro-Esophageal Reflux Disease) and 100 Milligram (mg) Docusate (constipation) R3's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents the following R2's medications were administered 2 hours or more before or after scheduled times; On 2/01/2025 100 Milligram (mg) Gabapentin was scheduled for 12:00 PM but was given at 2:04 PM; on 2/02/2025 100 Milligram (mg) Gabapentin was scheduled for 12:00 PM but was given at 3:43 PM; On 2/05/2025 100 Milligram (mg) Gabapentin was scheduled for 12:00 PM but was given at 4:09 PM ; on 2/06/2025 100 Milligram (mg) Gabapentin was scheduled for 7:00 AM but was given at 9:22 AM ; On 2/06/2025 500 Milligram (mg) Metformin was scheduled for 4:00 PM but was given at 6:17 PM; On 2/06/2025 50 Milligram (mg) Diclofenac and 100 Milligram (mg) Docusate was scheduled for 9:00 AM but was given at 11:24 AM ; On 2/06/2025 500 Milligram (mg) Metformin was scheduled for 4:00 PM but was given at 6:17 PM; On 2/12/2025 25 Milligram (mg) Quetiapine was scheduled for 2:00 PM but was given at 12:14 PM; On 2/13/2025 100 Milligram (mg) Gabapentin was scheduled for 7:00 AM but was given at 9:02 AM ; On 2/22/2025 100 Milligram (mg) Metformin was scheduled for 7:00 AM but was given at 9:10 AM ; On 2/23/2025 100 Milligram (mg) Docusate was scheduled for 9:00 AM but was given at 11:12 AM ; On 2/06/2025 50 Milligram (mg) Diclofenac was scheduled for 9:00 AM but was given at 11:11 AM. 4. R5's Face Sheet undated documents R5's admitting diagnosis Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Unspecified Asthma, Uncomplicated, Type 2 Diabetes Mellitus without Complications, Morbid (Severe) Obesity due to Excess Calories, Neuromuscular Dysfunction of Bladder, Unspecified, Fibromyalgia and Hypokalemia. R5's Physician Order Summary (POS) dated February 2025 documents medications as Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)Milligram/3 Milliliters (short of breath),80 mg Simethicone (gas) , 5 Milligram (mg) Oxycodone (pain) , 5 Milligram (mg) Diazepam (anxiety), 24 Microgram (mcg) Amitiza (Irritable Bowel Syndrome), 1.25 Milligram (mg) Ergocalciferol (supplement), 50 Microgram/ACT 146051 Page 3 of 5 146051 03/04/2025 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Fluticasone Propionate Nasal Suspension (allergies), 300 mg Bupropion, 325 mg Ferrous Sulfate (65 Fe), 40 Microgram (mg) Furosemide, 20 mg Furosemide (edema), 20 Milliequivalent (mEq) Potassium Chloride (supplement), 20 Milligram (mg) Prednisone (Pneumonia), 25 Milligram (mg) Lamictal (seizure), 25 Milligram (mg) Metoprolol (hypertension), 175 Microgram (mcg) Levothyroxine (low thyroid hormone) and 360 Milligram (mg) Cardizem (hypertension), 300 Milligram (mg) Bupropion Extended Release (depression) and 200 - 5 Microgram (mcg)/ ACT Milligram (mg) Dulera Inhalation Aerosol. R5's electronic medication administration (eMAR) dated 02/01/2025- 02/26/2025 documents the following of R5's medications were administered 2 hours or more before or after scheduled times ; On 2/3/2025 24 Microgram (mcg) Amitiza was scheduled for 6:00 AM but was given at 8:23 AM; On 2/3/2025 360 Milligram (mg) Cardizem, 200-5 Microgram (mcg)/ACT Dulera Inhalation, 40 Milligram (mg) Pepcid, 175 Microgram (mcg) Levothyroxine and 25 Milligram (mg) Metoprolol was scheduled for 8:00 AM but were administered between 5:39 and 5:41 AM ; On 2/3/2025 80 Milligram (mg) Simethicone and 0.5-2.5 (3) Milligram (mg)/3 Milliliter Ipratropium-Albuterol was scheduled for 12:00 PM but was given at 8:23 AM; On 2/5/2025 3 Milligram (mg)/3 Milliliter (ml) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 was scheduled for 6:00 PM but was given at 10:43 PM; On 2/6/2025 3 Milligram (mg)/3 Millimeter (ml) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 was scheduled for 12:00 AM but was given at 2:51 AM; On 2/7/2025 3 Milligram (mg)/3 Milliliter (ml) Ipratropium-Albuterol Inhalation Solution 0.5-2.5 was scheduled for 12:00 PM but was given at 2:01 PM; On 2/8/2025 40 mg Pepcid, 500 Microgram (mcg)Milligram (mg) Cyanocobalamin, 325 Milligram (mg) Ferrous Sulfate (65 Fe), 5 Milligram (mg) Apixaban, 25 Milligram (mg) Metoprolol, Multivitamin, 25 Milligram (mg) Lamictal, 10 Milligram (mg) Escitalopram, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem, 20 Milligram (mg) Prednisone, 20 Milliequivalent (mEq) Potassium Chloride, Lactobacillus, 20 Milligram (mg) Furosemide, 50 Milligram/ACT Nasal Suspension, 40 Milligram (mg) Furosemide, 100 Milligram (mg) Docusate, 200-5 Microgram (mcg)/ACT Dulera Inhalation Aerosol, and 300 Milligram (mg) Bupropion Extended Release was scheduled for 8:00 AM but was administered at 12:50 PM; On 2/10/2025 1.25 Milligram (mg) (50000 Unit) Ergocalciferol was scheduled for 7:45 AM but was administered at 12:32 PM ; On 2/10/2025 40 Milligram (mg) Pepcid, 500 Microgram (mcg) Cyanocobalamin, 325 Milligram (mg) Ferrous Sulfate (65 Fe), 5 Milligram (mg) Apixaban, 25 Milligram (mg) Metoprolol, Multivitamin, 25 Milligram (mg) Lamictal, 10 Milligram (mg) Escitalopram, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem, 20 Milligram (mg) Prednisone, 20 Milliequivalent (mEq) Potassium Chloride, Lactobacillus, 20 Milligram (mg) Furosemide, 50 Microgram (mcg)/ACT Nasal Suspension, 40 mg Furosemide, 100 mg Docusate, 200-5 mcg/ACT Dulera Inhalation Aerosol, and 300 mg Bupropion ER was scheduled for 8:00 AM but was administered at 12:32 PM; on 2/11/2025 80 mg Simethicone, 3 mg/3 ml Ipratropium-Albuterol Inhalation Solution 0.5-2.5 were scheduled for 12:00 PM but were administered at 2:12 PM ; On 2/12/2025 325 mg Ferrous Sulfate (65 Fe) and 40 mg Pepcid was scheduled for 8:00 AM but was administered 10:09, 10:12 AM, respectfully; On 2/12/2025 5 Milligram (mg) Apixaban, 500 Microgram (mcg) Cyanocobalamin, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem and 300 Milligram (mg) Bupropion, 200-5 Microgram (mcg)/ACT Dulera Inhalation Solution, 100 Milligram (mg) Docusate Sodium, 50 Microgram (mcg)/ACT Fluticasone Propionate Nasal Suspension and 10 Milligram (mg) Escitalopram, 40 Milligram (mg) Furosemide, 20 Milligram (mg) Furosemide , Lactobacillus and 25 Milligram (mg) Lamictal, 25 Milligram (mg) Metoprolol, Multivitamin, 20 Milliequivalent (mEq) Potassium Chloride Extended Release, 20 Milligram (mg) Prednisone and Lidocaine Patch 4% were scheduled for 8:00 AM but were administered between 10:06 AM and 10:16 AM; On 2/14/2025 5 Milligram (mg) Baclofen 1 Milligram (mg) Mirapex, 3 Milligram (mg) Melatonin and 80 Milligram (mg) Simethicone Lidocaine External Patch 4 % were scheduled for 8:00 PM but were administered at 10:38 146051 Page 4 of 5 146051 03/04/2025 Barry Healthcare & Sr Living 1313 Pratt Street Barry, IL 62312

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some PM and 10:46 PM ; On 2/22/2025 40 mg Pepcid, 500 Microgram (mcg) Cyanocobalamin, 325 milligram (mg) Ferrous Sulfate (65 Fe), 5 Milligram (mg) Apixaban, 25 milligram (mg) Metoprolol, Multivitamin, 25 Milligram (mg) Lamictal, 10 Milligram (mg) Escitalopram, 25 Milligram (mg) Diphenhydramine, 360 Milligram (mg) Cardizem, 20 Milligram (mg) Prednisone, 20 Milliequivalent (mEq) Potassium Chloride, Lactobacillus, 20 Milligram (mg) Furosemide, 50 Microgram (mcg)/ACT Nasal Suspension, 40 Milligram (mg) Furosemide, 100 Milligram (mg) Docusate, 200-5 Microgram (mcg)/ACT Dulera Inhalation Aerosol, and 300 Milligram (mg) Bupropion Extended Release was scheduled for 8:00 AM but was administered between 11:25 and 11:26 AM; On 2/24/2025 80 mg Simethicone, Lidocaine External Patch 4%, 5 mg Baclofen and 3 Milligram (mg) Melatonin was scheduled for 8:00 PM but was administered between 9:58 and 10:00 PM; On 2/26/2025 Clobatesol Propionate External Cream 0.05% was scheduled for 6:00 AM but was not administered to 10:09 AM; On 2/26/2025 Clobatesol Propionate External Cream 0.05% was scheduled for 6:00 PM but was not administered to 10:07 PM. On 3/1/2025 at 12:17 PM V8, LPN stated she has not contacted the doctor when she is late with med administration. It was inevitable because you have to address a resident's need if they come to you while you are passing medications. It does cause a delay. On 3/3/2025 at 12:53 PM V9 Wound Care Nurse Practitioner stated she might have been contacted about late medications once, but she was uncertain. The staff are pretty good about notifying her or the medical director if there is a problem. V9 could not say there was any harm in the delay of administering medications. They would like for the orders to be followed as prescribed. On 3/3/2025 at 1:52 PM V10 LPN stated neither she or any nurses in the building contacted the nurse practitioner or doctor when the medications were administered after the scheduled time. V10 LPN stated the medication rounds are too heavy, most of the residents' medications were shifted from the night shift to days and evenings therefore the medications cannot be administered in the allotted time frame. They have complained to the administration about the medication passes being too heavy, but nothing is being done about it. The Facility's Policy Administering Medications revised April 2019 documents medications are administered in accordance with prescribed orders, including any time frames. Medications are administered within 1 hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). 146051 Page 5 of 5