Inspection·May 22, 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 interview, observation, and record review the facility failed to remove expired medications from current medication supply for 2 (R17, R45) of 2 residents reviewed for pharmacy services in the sample of 35. Findings include: 1. R17's Face Sheet documents an admission date of 5/1/23 with diagnoses including in part fibromyalgia, lower abdominal pain, other chronic pain, pain in right hand, pain in left wrist, and pain in throat. R17's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition. R17's Continuity of Care Document dated May 22, 2025, documents an order for Tramadol (schedule IV narcotic) tablet 25 milligrams (mg) 1 tablet oral twice a day for pain ordered on 3/7/24 and discontinued on 5/20/25. On 5/20/25 at 11:24 AM, there was an expired card of tramadol HCL 50 mg half tablets for R17 in the medication cart with an expiration date of 2/14/25. R17's Medication Administration Record (MAR) dated 2/1/2025-2/28/2025 documents that R17 received tramadol 25 mg on 2/15/25 at 7:12 PM and 2/16/25 at 6:50 PM. R17's MAR dated 5/1/2025-5/20/2025 documents that R17 received tramadol 25 mg on 5/3/25 at 7:45 PM. On 5/20/25 at 12:20 PM, V4 (Registered Nurse/RN) confirmed the tramadol for R17 was expired. V4 removed the card from the medication cart and stated it should have been removed from the cart when it expired. V4 stated the director of nursing checks the medication carts for expired medication and a pharmacy representative was just in the facility and should have found it. 2. R45's Face Sheet documents an admission date of 2/8/24 with diagnoses including in part arthritis and pain. R45's MDS dated [DATE] documents a BIMS of 9 indicating moderately impaired cognition. R45's most recent Care Plan documents a problem of R45 is at risk for pain related to diagnosis of arthritis with a start date of 9/19/24, goal of R45 will have pain under control with medication or resolved as seen by verbalization or free of signs or symptoms of pain, and approach of observe effectiveness of medication and provide analgesics as ordered and as needed. R45's Continuity of Care Document dated May 22, 2025, documents a current order for albuterol sulfate solution for nebulization 0.63 mg/2 milliliters (ml) inhalation every 6 hours as needed ordered (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 5 Event ID: 146088 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 146088 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Helia Healthcare of Benton 1310 Mark Franklin Louis Street Benton, IL 62812 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)