Health inspection·October 10, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to prevent misappropriation of a residents medication in 1 of 4 residents (R2), reviewed for Misappropriation in the sample of 4. Residents Affected - Few Findings include: The Facility Final Report, dated 3/6/24, documents the following: On Thursday, February 29, 2024, during the evening, the administrator received notice that approximately 29.75 ml of concentrated liquid Ativan (2mg/ml) was missing from the nurse medication room properly stored in the locked refrigerator. Interviews of all staff nurses began. Management nurses reported to facility. All areas of the medication room, refrigerator, and both medication carts were searched. This same evening it was realized that pharmacy documents were missing as well (pink pharmacy sheets for usage and destruction) of missing medication. At that time large shred box was opened to find the pharmacy medication documents folded in half to be shredded. Interviews with nurses, whom all did respond by phone, were received this evening. After review of nurse schedule it was realized the time frame of the drug diversion occurred on 2/27/24. At this time, the administrator began review of surveillance for the nurse's medication room. It was found after multiple entries into the medication room by V3, LPN, and the following information to be factual and true. Camera footage shows said nurse on 2/27/24 at 2007 (8:07 PM) removing the box Ativan from the top shelf in the refrigerator door, then removes the bottle of liquid Ativan, flattens the package/box, and places the bottle in a small zipper bag and puts it in her purse. V3 then replaces the box in the trash and removes the trash. Later at approximately 2140 (9:40 PM), V3 takes her purse/bag out of the medication room/facility and to her car (just prior to 2200 (10 PM) nurse reporting to shift. V3 was spoken to multiple times and denied seeing the medication. V3 stated she was not aware of that medication and felt like she was being set up and continued to deny any involvement. On Friday 3/1/24, early morning, Pharmacy, Medical Director, Sheriff, IDPH (Illinois Department of Public Health), County Commissioners and the State's Attorney was notified. On this date the County Sheriff came to the facility to review surveillance and captured time frame when nurse is removing the missing controlled medication and takes it by putting it in her personal bag and later removes the bag from the facility to her car. Asked the surveillance company to capture time frame from incident and provide a USB drive to the facility. V3 very angry when advised she alone was being investigated for drug diversion and advised if she had anything to report or would like to speak with myself over the incident, she could and she refused. Administrator did not inform of surveillance as was instructed by law enforcement and the Department of Professional Regulations in this matter. We will continue to follow polices directly related to such event and will function to protect residents from such. R2's February Physician Order Sheet, documents an order, dated 2/23/24, for Lorazepam (Ativan) oral solution 2mg (milligrams) / ml (milliliter), 0.25ml every 4 hours as needed for anxiety/agitation. (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 2 Event ID: 146106 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 146106 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Scott County Nursing Center Rural Route 2 Winchester, IL 62694 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)