Health inspection·August 25, 2023

F 0554 outside of parameters of the orders, causing over- or under-dosing. Level of Harm - Minimal harm or potential for actual harm On 8/24/2023 at 10:30 AM, R54's August 2023 POS (Physician Order Sheet) showed an order for the menthol gel to be applied to the right shoulder, left knee and scapula, three times a day as Residents Affected - Few needed, for pain. R54's August 2023 POS also showed R54's order for the antifungal powder was discontinued on 08/20/2023. R54's POS showed no orders to keep either medication at the bedside. 2. R333's Face Sheet showed his diagnoses include chronic obstructive pulmonary disease and muscle weakness. R333's 8/13/23 Minimum Data Set (MDS) showed he is cognitively intact. On 08/22/23 at 12:24 PM, an albuterol metered-dose inhaler was on R333's desk. The inhaler was visible from the doorway. R333 stated the inhaler was left by the nursing staff and was for his use. The next day at 9:15 AM, R333's inhaler was again seen on his desk. On 08/23/23 at 09:18 AM, V4 RN (Registered Nurse) stated as far as he knew, R333 was not assessed for keeping medications at the bedside, he did not have orders to keep medications there, and R333 did not have orders to self-administer his own medications. On 08/24/23 at 09:57 AM, V2 DON (Director of Nursing) stated if residents do not have a physicians order to keep medication at the bedside, then medication should be stored in the medication cart and the nurse should be the only person to administer medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146173 If continuation sheet Page 2 of 4 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 146173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Monarch Landing, The 2308 North Route 59 Naperville, IL 60563 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents' medications were secured and labeled. This applies to 2 residents of 20 residents (R54, R333) reviewed for medication storage on the sample list of 30. Findings include: 1. R54's admission Record shows R54 was admitted on [DATE] and her diagnoses include gout, right shoulder and left knee pain, and obsessive-compulsive disorder. R54's 12/03/2022 cognitive function care plan showed she has impaired cognitive function related to a diagnosis of dementia, and her [Minimum Data Set] (MDS) scoring does not reflect cognitive fluctuations and forgetfulness that is observed by staff. On 08/22/2023 at 10:29 AM, R54 had an unlabeled tube of topical menthol pain reliever gel and an antifungal powder container on her nightstand on the right side of her bed. On 8/22/2023 at 10:30 AM, R54 said she regularly bought the menthol gel from an online retailer. R54 said she ordered the medication so she can always have and use it when she wanted to. R54 said she uses the gel on any part of her body that is hurting and she cannot remember how many times a day she uses it. R54 said she uses the antifungal powder on her groin after going to the bathroom. On 08/24/2023 at 09:55 AM, V2 (DON-Director of Nursing) said all medications are kept in the medication carts or the medication room. V2 said all medications should be labeled and the facility does not allow medication from outside sources. V2 said if unlabeled medications were found, they are returned to the family and the facility will obtain physician orders and obtain the medication from facility's pharmacy. On 8/24/2023 at 10:30 AM, R54's August 2023 POS (Physician Order Sheet) showed an order for the menthol gel to be applied to the right shoulder, left knee and scapula, three times a day as needed, for pain. R54's August 2023 POS also showed R54's order for the antifungal powder was discontinued on 08/20/2023. R54's POS showed no orders to keep either medication at the bedside. Facility's November 2020 policy on Storage of Medications showed Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . Facility's 1/29/2020 Policy on Labeling of Medication Containers showed .2. Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. For inadequately or improperly labeled medications from home or outside pharmacy, medication will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146173 If continuation sheet Page 3 of 4 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 146173 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Springs at Monarch Landing, The 2308 North Route 59 Naperville, IL 60563 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few returned to patient representative or back to patient at time of discharge . 4. Labels for over-the-counter drugs include all necessary information, such as: a. The original label indicating the name, strength, and quantity of the medication; b. The expiration date when aplicable; c. Directions for use and appropriate accessory/cautionary statements 2. 1. R333's Face Sheet showed his diagnoses include chronic obstructive pulmonary disease and muscle weakness. R333's 8/13/23 Minimum Data Set (MDS) showed he is cognitively intact. On 08/22/23 at 12:24 PM, an albuterol metered-dose inhaler was on R333's desk. The inhaler was visible from the doorway. R333 stated the inhaler was left by the nursing staff and was for his use. The next day (8/23/23) at 9:15 AM, R333's inhaler was again seen on his desk. On 08/23/23 at 09:18 AM, V4 RN (Registered Nurse) stated as far as he knew, R333 was not assessed for keeping medications at the bedside, he did not have orders to keep medications there. On 08/24/23 at 09:57 AM, V2 DON (Director of Nursing) stated if residents do not have a physicians order to keep medication at the bedside, then medication should be stored in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146173 If continuation sheet Page 4 of 4