Health inspection·August 19, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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 and record review, the facility failed to administer prescribed medications at the prescribed time. This failure has the potential to affect all 49 residents residing in the facility. Findings include:1. R3's Face Sheet documents an admission date of 11/23/22, with diagnoses including chronic kidney disease, chronic obstructive pulmonary disease, chronic venous hypertension, chronic congestive heart failure, and type 2 diabetes mellitus.R3's Minimum Data Set (MDS), dated [DATE] in section C, documents R3 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. Section N of same MDS documents R3 is ordered the following classes of medications: diuretic, opioid, antiplatelet, and hypoglycemic (insulin).R3's Care Plan, dated 7/17/25, documents a focus area that R3 is on diuretic therapy related to edema. Interventions for this focus area include administering diuretic medications as ordered by physician with an initiation date of 4/10/23. Another focus area documents that R3 has a mood problem. Documented interventions for this focus area include administer medication as ordered with an initiation date of 1/6/23.R3's July 2025 Medication Administration Records (MAR) documents R3 has medications scheduled to be administered at the following times: 7:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 5:00 PM, and 8:00 PM. R3's MAR provided did not document the actual time the medication was administered.A Resident Grievance form filed by R3, dated 6/19/25, states R3 voiced concerns with timeliness of medication pass at night.On 8/13/25 at 9:54 AM, R3 stated she frequently doesn't get her 8:00 PM medications until midnight. R3 stated in one instance, she did not get her scheduled 8:00 AM medications until 2:00 PM in the afternoon. 2. R4's Face Sheet documents an admission date 2/25/25, with diagnoses including, but are not limited to, depression, hypertension, hypothyroidism, and osteoarthritis.R4's MDS, dated [DATE], documents in section C that R4 has a BIMS score of 13, indicating R4 is cognitively intact. Section N of same MDS documents R4 is on the current class of medications: antidepressant, diuretic, opioid, antiplatelet, and hypoglycemic.R4's Care Plan, dated 8/4/25, documents a focus area of R4 takes a psychotropic medication. A related intervention to the previous focus area includes administering medications as indicated by physician orders, with an initiation date of 8/1/25. Another focus area documents R4 has hypertension. A related intervention is to give antihypertensive medications as ordered, with an initiation date of 5/22/25. Another focus area on the R4's Care Plan documents R4 has diabetes mellitus. A related intervention for this focus area is to administer diabetes medication as ordered by doctor, with an initiation date of 5/22/25. Another focus area listed on R4's CP is she has chronic pain related to other chronic pain, osteoarthritis, carpal tunnel syndrome and depression. A related intervention includes to administer analgesia as per orders, with an initiation date of 2/25/25.R4's July 2025 Medication Administration Records (MAR) documents R4 has medications scheduled to be administered at the following times: 5:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, 5:00 PM, and 8:00 PM. R4's MAR provided did not document the actual time the medication was administered.On 8/13/25 at 9:37 Page 1 of 4 146119 146119 08/19/2025 The Haven on the River 320 South 2nd Street Grayville, IL 62844

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many AM, R4 stated she often doesn't get her scheduled 8:00 PM medications until 10:30 PM or 11:00 PM. R4 stated one time she didn't get her 8:00 PM medications until 12:30 AM.On 8/18/25 at 11:34 AM, V7, Licensed Practical Nurse (LPN) stated she is often over the ordered time range of two hours for medication administration, by up to one and a half hours. V7 gave the example of the 8:00 PM medication pass should be completed by 9:00 PM, but she is frequently not finished until 10:30 PM. V7 stated the 8:00 PM medication pass is a large one, and it needs two nurses to get it completed in the ordered time range.On 8/18/25 at 3:20 PM, upon this surveyor asking for July MAR's for R3 and R4 with documented and timestamped medication administration times from V2, Director of Nursing/DON, he stated he was instructed by his superior, V24, Chief Operating Officer, not to turn the time stamped MAR's over to this surveyor because the facility had started an internal Quality Assurance investigation, and those documents were now considered confidential. V2 stated he had been instructed by his superior to not allow this surveyor to even visualize the time stamped MAR's in the Electronic Health Record on V2's computer. V2 stated the internal investigation was started approximately 2-3 weeks ago. V2 stated the internal investigation was started when R3 and R4 had brought it to administration's attention that medications were being administered past the ordered time ranges. V2 stated he has had complaints from floor nurses the medication passes are too large to be completed in the ordered time range of two hours. V2 stated presently, at times, R3 and R4 are continuing to complain medications are being administered past the ordered time range.On 8/13/25 at 1:47 PM, V8, Certified Nurse's Aide (CNA), stated R3 has specifically mentioned to him she had not gotten her medications on time specifically when V4, Registered Nurse (RN), was working.On 8/13/25 at 2:14 PM, V11, CNA, stated she has had complaints from residents about getting their medications late, past the ordered time range, but she was unable to recall any names.On 8/13/25 at 2:32 PM, V13, CNA, stated she has had multiple residents complain that they did not get their medications administered at the correct time. V13 stated in the past, she also has had R3 and R4 complain about their medications being administered late past the ordered time range. V13 also stated she had residents complain to her (couldn't remember who) V4, RN, had left for two hours one evening when she was supposed to have been administering medications.On 8/14/25 at 8:15 AM, V14, CNA, stated she has had multiple complaints from residents about not getting their medications administered at the ordered time frame especially when V4, RN, was working. The residents who mentioned this to her were specifically complaining they were not getting their 5:00 PM or 8:00 PM medications at all.V4, RN, no longer works at the facility and was unable to be reached for an interview.On 8/14/25 at 10:01 AM, V15, CNA, stated she had many residents complain to her they were not getting their medications until past the ordered time range, especially on the midnight shift from 6:00 PM-6:00 AM.On 8/14/25 at 12:44 PM, V2, Director of Nurses (DON), stated there are some nurses, especially on midnight shift, struggling to get medications administered within the ordered time range. On 8/14/25 at 3:00 PM, V23, RN, stated on occasion, she is 1-2 hours out of the ordered time range for administering the medications ordered to the residents.On 8/14/25 at 3:31 PM, V21, RN, stated when she worked the floor, she would be past the ordered time range to administer medications one out of every three shifts on average every week. V21 stated she was up to 30 minutes to one hour past the ordered time range.On 8/18/25 at 10:01 AM, V17, RN, stated she frequently goes over the ordered time range for medication administration by approximately thirty minutes.On 8/18/25 at 10:26 AM, V5, RN, stated she is usually 10-15 minutes up to thirty minutes over the ordered time range for administering medications.The Resident Council meeting minutes, dated 7/17/25 at 2:00 PM, documents residents voiced concerns about not being administered their pain medications on time.The facility's Medication Administration Policy, with a revised date of 9/17/22, states, 146119 Page 2 of 4 146119 08/19/2025 The Haven on the River 320 South 2nd Street Grayville, IL 62844

F 0755 Level of Harm - Minimal harm or potential for actual harm Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe.The facility's Daily Census sheet, dated 8/13/25, documents there are 49 residents residing in the facility. Residents Affected - Many 146119 Page 3 of 4 146119 08/19/2025 The Haven on the River 320 South 2nd Street Grayville, IL 62844

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to provide medical records requested to aide in the survey process for 2 of 2 residents (R3 and R4) reviewed for medication administration in a sample of 19.Findings includeOn 8/14/25, this surveyor reviewed the July 2025 Medication Administration Records (MAR's) for R3 and R4 in their Electronic Health Records. The MAR's for R3 and R4 did not document the actual time the medication was administered.On 8/14/25 at 3:30 PM, this surveyor requested R3 and R4's July 2025 MAR's with documented and timestamped medication administration times from V2, Director of Nurses (DON).On 8/18/25 at 8:00 AM, V2, DON, stated he had been instructed by V24, Chief Operating Officer, not to provide the copies of R3 and R4's MAR's with documentation of the times the medications were administered or allow this surveyor to visualize them in the Electronic Health Record.On 8/18/25 at 3:20 PM, V2, DON, he stated he was instructed by V24 not to turn the time stamped MAR's R3 and R4 over to this surveyor because the facility had started an internal Quality Assurance investigation, and those documents were now considered confidential. V2 stated the internal investigation was started approximately 2-3 weeks ago. V2 stated the internal investigation was started when R3 and R4 had brought it to administration's attention that medications were being administered past the ordered time ranges. 146119 Page 4 of 4