Inspection·September 19, 2023

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 medication cart and enclosed narcotic box were kept locked and the keys remained with the nurse passing medications. This has the ability to affect all 30 residents living in the facility. Findings include: On 9/15/23 at 7:45am, V2 (Registered Nurse/RN) stated all the facility's residents are currently being housed on the South Hall due to renovations occurring on the North Hall. On 9/15/23 at 10:15am, V2 stated the only staff members who have keys to the medication room and the medication cart with enclosed narcotics box is the nurse who is passing medications that day. On 9/15/23 at 11:15am, V2 was observed passing medications on the South Hall. V2 prepared for administration of R2's medications. Afterward, V2 did not lock the medication cart or the narcotics box and walked into R2's room where the cart, still in the hallway, was not within V2's visual control. On 9/15/23 at 11:40am, V2 was observed preparing medications for administration to R7. V2 did not lock the cart or the narcotic box and walked into R7's room where the cart was not within V2's visual control. R11 was observed in a wheelchair self-propelling by the unlocked cart. On 9/15/23 at 12:00pm, V2 was observed preparing medications for administration to R6. V2 did not lock the medication cart or the narcotics box and left the key to the narcotic box on top of the cart. V2 went into R6's room, where the cart was not within V2's visual control. On 09/19/23 at 8:30am, V7 (Corporate Quality Assurance/RN), stated the medication cart and the narcotics box is to be locked when not in the nurse's visual control, and the keys are to remain with the nurse at all times. On 9/19/23 at 9:35am, the Surveyor attempted to interview R11 in the facility's Dining Room. R11 was alert only to self. A Controlled Substances Policy dated 11/2/17 documented, Schedule 2 drugs are to be kept under two separate locks requiring two separate keys. A permanently affixed locked cabinet within the locked medication cart may be used for safe keeping. The schedule 2 cabinet must remain locked, and the charge nurse shall have the key in her possession at all times. Only licensed nurses will have access to controlled substances. A Medication Administration Policy dated 7/3/13 documented,#5. Keep the (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: 146121 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 146121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benton Rehabilitation and Health Care Center 1409 North Main 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)