Health inspection·September 30, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure physician prescribed medication was obtained and administered for 1 of 3 residents (R1) reviewed for pharmacy services in the sample of 5. The findings include: R1's face sheet shows he was admitted to the facility on [DATE] with diagnoses including: adult failure to thrive, urinary retention, unspecified dementia, and protein calorie malnutrition. R1's nursing progress notes show he was sent to a local emergency room on 9/11/24 for increased weakness, confusion and having amber colored urine in his indwelling Foley catheter. Nursing progress notes show R1 returned from the hospital on 9/12/24 at 2:30 PM and was diagnosed with a urinary tract infection (UTI). R1's 9/12/24 After Visit Summary from a local community hospital shows his discharge medications to include levofloxacin (Levaquin) (an antibiotic) 500 mg. (milligrams) to be taken daily for 5 days for a UTI. R1's Physician Order Report for 9/1/24-9/26/24 shows an order for R1 to begin levofloxacin 500 mg to be given daily for 5 days beginning 9/12/24 between 3:00-6:00 PM. R1's Medication Administration Record from 9/12/24-9/26/24 shows he did not receive his scheduled levofloxacin on 9/12/24 or 9/13/24 with the reason coded as Not Administered: Drug/Item unavailable. On 9/26/24 at 12:01 PM, V12 (Licensed Practical Nurse) said the facility has an onsite medication distribution system called stat safe which has numerous medications available they can access. V12 said she was not aware that R1 missed 2 days of his antibiotic and she would have called the pharmacy to see where the medication was. On 9/26/24 at 12:20 PM, V7 (Registered Nurse) said she noticed a few days later that R1 had missed 2 doses of his antibiotic and if she was the nurse who was scheduled to have given the antibiotic, she would have called the pharmacy to find out where the medication was or obtain it from the state safe and given it. V7 said the facility pharmacy can be slow at delivering medications. On 9/26/24 at 1:33 PM, V6 (Pharmacist) said they received the order for R1's levofloxacin on 9/12/24 at 2:57 PM and delivered it to the facility on 9/13/24 at 2:10 AM. V6 said the consequence of R1 missing the doses of antibiotics could result in worsening systems of his infection or becoming Page 1 of 2 146193 146193 09/30/2024 Manor Court of Rochelle 2203 Flagg Road Rochelle, IL 61068

F 0755 septic. Level of Harm - Minimal harm or potential for actual harm On 9/26/24 at 1:43 PM, V3 (R1's physician) said he does not recall the facility calling him to inform him that R1 missed the 2 doses of his antibiotic. V3 said this medication was ordered by the hospital physician so it should have been followed and given as scheduled. Residents Affected - Few The facility provided list of medications inside the safe stat medication box shows levofloxacin 250 mg. and 500 mg. were both inside. The facility provided Pharmaceutical Procedures Policy revised on 1/5/23 shows the facility and pharmacy should provide the residents with the appropriate distribution and administration of medications. 146193 Page 2 of 2