Health inspection·July 15, 2024

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. Based on observation, interview and record review, the facility failed to provide and acquire medications as ordered by the doctor to meet the needs of each resident. These failures could potentially affect 2 (R1 and R5) of 5 residents reviewed for improper nursing care. The findings include: R1's face sheet documented admission date on 4/5/2024 with diagnoses not limited to Chronic obstructive pulmonary disease, Transient cerebral ischemic attack, Suicidal ideations, Antiphospholipid syndrome, Coagulation defect, Hypertensive heart disease without heart failure, Hematuria, Hyperlipidemia, Calculus of kidney, Systemic lupus erythematosus, Unspecified urinary incontinence, Personal history of transient ischemic attack, and cerebral infarction without residual deficits, Major depressive disorder. R5's face sheet documented admission date on 2/1/2024 with diagnoses not limited to Type 2 diabetes mellitus with foot ulcer, Chronic obstructive pulmonary disease, Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed, Major depressive disorder, Hypertensive heart disease with heart failure, Non-pressure chronic ulcer of other part of right foot with fat layer exposed, Hypoglycemia, Chronic kidney disease, Anemia, Altered mental status, Hypo-osmolality and hyponatremia, Overactive bladder, Hyperlipidemia, Gastro-esophageal reflux disease without esophagitis, Schizophrenia, Schizoaffective disorder. On 7/14/24 at 11:05am Observed R1 up and about, alert, and oriented x 4, verbally responsive. R1 said she has been residing in the facility for 3 months and did not get her COPD (Chronic obstructive pulmonary disease) inhaler (Symbicort and Albuterol) since she came to the facility. R1 stated inhaler was not available. R1 said the physician / nurse practitioner and nurses are aware and was told that they will order the inhaler. R1 said she is having constant mucus in her lung, having problem with breathing at times. R1 said today she is okay. R1 said she has been taking her inhaler (Symbicort) twice a day for 12 years and she has another as needed inhaler (albuterol) if she needs it for hard time breathing. R1 stated she kept asking the nurses since admission, but she was told that inhaler was not available, and it was not given to her. R1 observed breathing easy, no shortness of breath. At 11:28am V4 (Licensed Practical Nurse / LPN) said has been working in the facility since 2018. V4 stated she is taking care R1, did not see R1 having hard time or difficulty breathing and R1 did not ask her for inhaler. V4 checked R1's physician order for inhaler and stated R1 has an order for Page 1 of 2 146164 146164 07/15/2024 Community Care Nursing Center 4314 South Wabash Avenue Chicago, IL 60653

F 0755 Level of Harm - Minimal harm or potential for actual harm albuterol inhaler as needed. V4 and surveyor inspected medication cart. Albuterol inhaler was not found or not available. V4 said she will order it to the pharmacy. V4 asked R1 if she needed the inhaler or is having a hard time breathing and R1 stated she is okay right now. R1 stated she has been taking Symbicort twice a day for a long time and albuterol as her rescue inhaler. V4 told R1 that she will call physician to get an order and inform pharmacy to deliver the inhalers. Residents Affected - Few R1 POS (physician order sheet) showed Albuterol-Budesonide aerosol 2 inhalation inhale orally every 6 hours as needed for COPD. Order dated 4/5/24. MDS (minimum data set) dated 4/12/2024 showed R1's cognition was intact. At 12:54pm Medication observation conducted with V5 (Licensed Practical Nurse / LPN). Observed V5 check R5's blood sugar and showed 255. V5 prepared Humulin R 4 units and administered subcutaneously to R5's left lower abdomen. R5's MAR documented: Humulin R Injection Solution 100 UNIT/ML Inject as per sliding scale. Scheduled at 9am 11am and 4pm. At 2:28pm V2 (Director of Nursing / DON) said V2 has been working in the facility since March 2024. V2 said nurses are expected to give or administered medications as prescribed by the doctor. Nurses are expected to follow the 5 R's (Right resident, right medication, right dose, right route, and right time) in giving meds. If medication is ordered or scheduled at 11am, it should be given at 10am and not later than 12 noon. If medication was given past 12 noon, it is considered a medication error because it was not given on a prescribed time. V2 said resident could have an adverse reaction especially if medication is given multiple times a day, medication could be administered too close to the next scheduled time and could potentially have an adverse reaction to the resident. V2 said PRN (as needed) medication should always be available in the medication cart because the resident could need the medication at any time and should be given as ordered. If PRN medication is not available, the medication could be missed by resident if they need it. V2 said PRN Inhaler medication for COPD should always be available so if resident needs, it could be given right away as ordered otherwise resident may have respiratory issue if they are not able to get the medication they need. Facility's concern form dated 6/28/24 showed R1 had reported about not receiving her inhaler. Medication administration policy dated 3/2024 documented in part: To ensure that the administration of medications is performed in a safe manner to prevent medication errors. Medications are administered according to state and federal law. Medication preparation / administration: Five rights - right medication, right dose, right time (60 minute before and after the scheduled time unless otherwise specified), right route, right resident. 146164 Page 2 of 2