Inspection·September 5, 2024

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 monitor and dispose of expired insulin medication per the facility policy for Insulin Pens. The facility failed to remove the insulin pen after 28 days of opening per manufacturer recommendation. This deficiency affects one of two medication carts (2nd Floor Middle Cart) reviewed for Safe Medication Storage. This failure affected 1 (R63) of 3 residents reviewed for medication label and storage. Findings include: On [DATE] at 11:00AM, surveyor observed 2nd Floor Middle Cart [NAME] with V5 (Registered Nurse/RN) and discovered an expired Lantus Kwikpen dated [DATE] - [DATE], Lot#4F9646A. When asked V5 (Registered Nurse) responded that it should have been disposed of after 28 days and wasn't sure why it was still in the medication cart. When asked if it was used recently for R63, V5 (RN) checked the EMAR and confirmed that it was used the previous night by the evening nurse. V5 (RN) did remove and dispose of the expired Lantus Kwikpen from the medication cart while in the presence of the surveyor. V5 (Registered Nurse) stated that she was going to let pharmacy know about the expired insulin medication for R63. R63's EMAR on [DATE] at 9:57PM showed she received 7units of Lantus Insulin On [DATE] at 11:30AM, informed V2 (Director of Nursing/DON), V2 states that depending on the brand of insulin pens once opened they are good for 28/30 days and newer brands can be used even longer. V2 (DON) states that nurses are educated on insulin administration and are instructed that insulin pens are only good for 28/30 days after first use. V2 (DON) states the facility had an all-nurse staff in-service within the last 2-3 weeks. When asked how often carts are audited and by whom V2(DON) states monthly audits are performed by pharmacy and shift nurse should check the medication cart for medications that are expiring the next 3-4 days to insure they are refilled. V2 (DON) states he had R63 assessed vitals, blood glucose, and all within normal limits. V2 (DON) states he called R63's POA to inform them that a expired insulin was administered. V2 (DON) states R63 reports feeling fine, no issues or concerns. On [DATE] at 1:59 PM, surveyor attempted to call V6 (Registered Nurse/RN) regarding patient care on the evening of [DATE] for R63. Left voicemail. Medication administration records from ([DATE] through [DATE]) showed evening administrations of Lantus insulin (7 units) for R63 as of start date of [DATE]. (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: 146180 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 146180 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ascension Nazarethville Place 300 North River Road Des Plaines, IL 60016 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)