Health inspection·May 2, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 4/19/25 discharge orders for his scheduled doses of atorvastatin and montelukast showed next dose: today (4/19/25) at bedtime. R1's April 2025 MAR (Medication Administration Record) showed his 4/19/25 doses of atorvastatin and montelukast scheduled at 8:00 PM simply had an X. R1's 4/19/25 discharge orders for five other medications (meloxicam, pantoprazole, sertraline, tamsulosin and an Incruse inhaler) showed next dose: tomorrow (4/20/2025) morning. R1's April 2025 MAR showed a 5 or a 9 for his 6:00 AM pantoprazole ad sertraline doses and his 8:00 AM doses of his Incruse inhaler, meloxicam, tamsulosin, Symbicort inhaler, and his buprenorphine/naloxone. Per the legend on the MAR, a checkmark indicates a medication was administered, and a 5 or 9 is a referral to a progress note. R1's 4/20/25 MAR progress notes from 8:53 AM showed meds not delivered yet, on way and 9:22 AM showed .will call pharm to see when delivery of narcotics and any missing meds . Notes from 11:57 for R1's Symbicort inhaler showed not available; at 12:04 PM for meloxicam n/a; 12:06 PM for pantoprazole n/a; and 3:51 PM for sertraline not done. The pharmacy medication delivery sign-in sheet showed R1's medications were delivered on 4/20/2025 at 2:26 PM, and were received by V4, LPN. 2. R2's Face Sheet showed she was admitted to the facility on [DATE]. R2's MDS showed she was cognitively intact. R2's Face Sheet showed her diagnoses include diabetes, peripheral vascular disease, congestive heart failure, stage 4 kidney disease, cerebral infarction, transient ischemic attacks, and pulmonary hypertension. On 4/28/25 at 12:45PM, V7 (R2's family) stated when she asked about R2's medications on Sunday 4/20/25, staff told her R2's medications were discontinued until Monday (4/21), and R2 did not get her medications. V7 stated R2 had been living in an Assisted Living and they had called her because they got a fax about R2's medication and she was no longer there. V7 stated she went to the Assisted Living and got all R2's medications to bring to the skilled care. V7 stated around 4:00 PM on Monday, she was told R2's medication arrived from the pharmacy, and the facility no longer needed the medications from the Assisted Living. On 4/28/25 at 1:37 PM, V8, RN (Registered Nurse), stated as soon a new admission comes in, staff look at the medication list that come from the hospital with the discharge instructions. V8 stated nurses enter the medications one at a time into the computer in the physician orders, then then pharmacy takes over. R2's hospital discharge orders from 4/19/25 showed she was to receive clopidogrel and Lasix next dose: today (4/19/25) evening, her Humalog insulin next dose: today (4/19/25) evening with meal, and her hydralazine next dose: today (4/19/25) at bedtime. The discharge orders also showed R2 was to receive six other medications (famotidine, fluoxetine, Farxiga, losartan, metolazone, and prednisone) next dose: tomorrow (4/20/25) morning, and levothyroxine next dose: tomorrow (4/20/25) morning before meal. R2's progress notes showed her medication orders were not entered in the computer until 4/20/25, starting at 6:39 PM, on Sunday. R2's Physician Order Sheet showed the orders were put in on the 4/20/25, and medications were to start being administered on Monday, 4/21/25. The pharmacy medication delivery manifest showed ten of R2's medications were delivered on Monday 4/21/25, and signed for by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146077 If continuation sheet Page 2 of 3 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 146077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Serenity Estates at Morris 1223 Edgewater Morris, IL 60450 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility staff at 3:33 PM. R2's April MAR showed she missed twelve doses of various oral medications, three scheduled doses of insulin, and potentially five doses of sliding scale insulin. R2's progress note from 4/20/25 at 9:49 PM showed, Patient was admitted to (facility) at [4 PM] on 4/19/25. On 4/29/25 at 2:38 PM, V1 (Administrator) verified there was no documentation showing the physicians were notified about the medication administration delays. The facility's March 2023 Pharmacy Hours and Delivery Schedule policy showed, New orders and refill requests may be faxed or sent electronically at any time Facility-specific fax cut-off times are arranged between the facility and pharmacy New orders communicated to the [name] pharmacy after the cut-off time will automatically go into the next regular delivery for the facility . If .the resident is in need of medication as a STAT order, the medication should be started from the emergency dispensing kit if applicable, and/or an emergency delivery must be requested An emergency delivery can be requested by sending the order to the [name] pharmacy, contact the pharmacy by phone to alert them that you sent a STAT order . The facility's Unavailable Medications policy (implemented 8/1/24) showed, .4. Staff shall take immediate action when it is known that the medication is unavailable determine what efforts have been attempted by the facility or pharmacy provider to obtain the medication Notify Physician of inability to obtain medication medication .obtain alternative treatment orders and/or specific orders for monitoring . 5. Staff shall follow procedures for medication errors, including physician/family notification . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146077 If continuation sheet Page 3 of 3