Inspection·September 12, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review the facility failed to ensure a multi-dose vial was labeled when opened and failed to ensure controlled medications were double locked. This has the potential to affect all residents in the facility. The findings include: The CMS 671 form dated 9/10/24 showed six residents reside in the certified unit of the facility. 1. On 9/12/24 at 9:05 AM, the facility medication room was reviewed. The unit refrigerator had an opened vial of multi-dose tuberculin (TB) solution inside, and it was approximately half dispensed. The vial was not dated or labeled with an open or expiration day. V9 (Registered Nurse) was present and verified the vial was half used and there was no labeling. On 9/12/24 at 10:52 AM, V2 (Director of Nurses) stated the vial should have been dated when it was opened. It should show the date, time, and initials of the nurse that opened it. The information is important to ensure the solution is not used past the expiration day. There is no way of knowing if it is still effective if the date it was opened is missing. The facility's Maintenance of Medication Inventory policy last review dated 8/23 states: Opened multi-dose bottle such as TB solution should have a date opened sticker, if expires in 24 hours or less order replacement (expires in 30 days after opened). 2. R3's face sheet printed on 9/12/24 showed an admission date of 8/6/24. R3's physician order report showed an order start dated 9/2/24 for alprazolam (anxiety medication) at 0.25 milligrams every 24 hours as needed for sleeplessness. The same report showed an order start dated 8/7/24 for pregabalin (convulsion medication) at 50 milligrams two times a day for anticonvulsant. R57's face sheet printed on 9/12/24 showed and admission date of 8/31/24. R57's physician order report showed an order start dated 9/1/24 for pregabalin at 100 milligrams three times a day for anticonvulsant. On 9/12/24 at 9:05 AM, the facility medication cart was reviewed. The bottom drawer of the cart contained the narcotics box, and the lid was unlocked. R3's alprazolam and pregabalin medication cards where in the box. R57's pregabalin medication cards were in the box. V9 (Registered Nurse) stated the lid tends to catch on the top of the medication cards and block it from locking. It happens a lot. It should not be unlocked like that. (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: 146105 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 146105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Crest 2944 Greenwood Acres Drive Dekalb, IL 60115 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)