Health inspection·November 30, 2022

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy to assess a resident for self-administration of medications. Residents Affected - Few This applies to 1 of 1 resident (R32) reviewed for self-administration of medications in a sample of 18. The findings include: R32's EMR (Electronic Medical Record) showed R32 was admitted to the facility on [DATE] with multiple diagnoses including pulmonary embolism, thrombosis of the right femoral vein, and endometrial cancer. R32's MDS (Minimum Data Set), dated 11/10/22, showed R32 was cognitively intact. On 11/28/22 at 1:34 PM, R32 was sitting in her room in her wheelchair. R32 had a medication cup on her bedside table with two medications in the cup. R32 said one of the medications in the cup was her rivaroxaban (blood thinner). R32 continued to say the nurse leaves the medications at her bedside, and R32 does not take them right away. R32 said she knows she is not supposed to wait to take the medications, but she does wait to take the medications. On 11/30/22 at 10:27 AM, R32 was sitting in her room in her wheelchair. R32 had a medication cup on her bedside table with medications in the cup. R32 said the nurse left the medications for her to take. R32 continued to say she had not taken the medications yet. On 11/30/22 at 11:15 AM, V9 (RN/Registered Nurse) said R32 has a care plan to say R32 can self-administer her medications. V9 continued to say V9 will leave R32's medications and follow up later with R32. On 11/30/22 at 11:22 AM, V2 (DON/Director of Nursing) said the facility does not have a resident who has requested to self-administer their medications. V2 continued to say for a resident to be able to self-administer medications, the resident needs to be assessed to see if the resident can follow instructions about medication administration and understand the medications. V2 said the resident needs a physician order for self-administration of medication and a form completed in the EMR prior to the resident being able to self-administer medications. V2 continued to say the nurse should be verifying with the resident the medication was taken prior to documenting the administration of the medication on the MAR (Medication Administration Record). (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 4 Event ID: 146061 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 146061 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Plaza Lisle Snf 1800 Robin Lane Lisle, IL 60532 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)