Health inspection·January 9, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure two residents (R1, R2) received their evening medications in a timely manner. This applies to 2 of 10 residents (R1, R2) reviewed for nursing care in the sample of 10. Residents Affected - Few The findings include: On 1/9/25 at 12:50 PM, R2 said on 1/4/25, R2 and R1 (R1's roommate) requested their evening medications from V7 multiple times and V7 argued with R1 and R2 insisting that V7 administered their evening medications. R1 and R2 both stated V7 did not appear to be under the influence during this discussion. R1's January Medication Administration Record (MAR) shows that all R1's evening medications for 1/4/25 were signed as given by V2 (Director of Nursing). R2's January MAR shows that all R2's evening medications for 1/4/25 were signed as given by V2. On 1/9/25 at 10:54 AM, V2 said on 1/4/25, V7 (LPN) sent V2 a text message at approximately 10:50 PM that read, I'm so k of these delusional ass home telling me I'm not giving them meds . I can drop me all day long they I wild b clean. (sic) V2 awoke at approximately 11:20 PM on 1/4/25, read the text message, and called V7. V2 said V7 was exhibiting slurred speech while on the phone. V2 then called V5 (LPN) who was also working and asked V5 to check on V7. V5 told V2 that V7 was stumbling and had slurred speech. V2 told V5 to stay with V7 and to not let V7 have contact with any residents and to not let V7 go into the medication cart. V2 notified V1 (Administrator) and V2 and V1 drove to the facility. When V2 and V1 arrived at the facility at approximately 1:20 AM on 1/5/25, they asked V7 if V7 would consent to a drug test and V7 asked if cannabis would count. V2 informed V7 that cannabis would count to which V7 responded that V7 would test positive. V7's Screening Result Form dated 1/5/25 shows V7 had positive results for amphetamines, benzodiazepines, cocaine, and methamphetamine. V7's Pre-Employment Screening Result Form dated 6/26/24 shows V7 has prescriptions of amphetamines and benzodiazepines and V7 was educated about these medications while working. On 1/9/25 at 10:54 AM, V2 said when the drug results were read to V1 and V7, V7 admitted to doing a bump of cocaine over the holidays with V7's sister but denied having done any drugs on 1/4/25 or using methamphetamine. V1 and V2 sent V7 home with V9 (Certified Nursing Assistant- CNA) who said she is neighbors with V7. When V7 left the facility, V2 provided R1 and R2 with their evening medications that were missed. Page 1 of 2 146069 146069 01/09/2025 East Bank Center, LLC 6131 Park Ridge Road Loves Park, IL 61111

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 1/9/25 at 12:37 PM, V10 (Nurse Practitioner) said V2 notified V10 of the delayed medications and due to the half-life of the medications, them being delayed caused none of the residents any negative outcomes or side effects. V10 also assessed both residents after the incident and had no concerns. On 1/9/25 at 12:50 PM, R1 and R2 stated they did not experience any side effects from the missed medications on 1/4/25. On 1/9/25 at 2:10 PM, V2 stated it is the expectation that staff should not be under the influence of drugs or alcohol while they are on the clock and R1 and R2 should have received their medications during the evening medication pass. 146069 Page 2 of 2