Health inspection·August 7, 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 administer medications timely in accordance with the facility policy. This applies to 2 of 3 (R2, R4,) in a sample of 3 reviewed for timely administration of medications. The findings include: R4's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including [NAME] Barre Syndrome, [NAME] Nile virus, pulmonary embolism without acute cor pulmonale, And generalized muscle weakness. R4's MDS (Minimum Data Set) dated July 23, 2024, showed R4 was cognitively intact, and was dependent on staff assistance with ADLs including eating, oral hygiene, bed mobility, bathing, dressing, toilet hygiene, and transfer. R4's Medication Administration Audit report, dated July 26, 2024-July 27, 2024, showed R4 medication scheduled to be administered at 9:00 AM, included Amlodipine Besylate tablet 2.5 mg, (milligrams) daily, Metoprolol Tartrate tablet 25 mg, twice a day, Apixaban 5 mg. twice a day, Aspirin 81 mg. daily, Ferrous Sulfate tablet 325 mg, daily, Thiamine HCL tablet 100 mg daily, Folic Acid 1 mg daily and Megestrol Acetate suspension 400mg/10ml(milliliters) daily. The Medication Audit report showed the scheduled 9:00 AM medications on July 26, 2024, were administered as follows: Amlodipine Besylate at 10:58 AM, Metoprolol Tartrate at 10:58 AM, Apixaban at 10:57 AM, Aspirin at 11:00 AM, Ferrous Sulfate at 10:59 AM Thiamine at 11:00 AM, Folic Acid at 10 :59 AM and Megestrol Acetate at 11:01 AM. The Medication Audit report showed the scheduled 9:00 AM medications on July 27, 2024, were administered as follows: Amlodipine at 11:25 AM, Megestrol Acetate at 11:27 AM, Thiamine at 11:28 AM, Folic Acid at 11:27 AM, Aspirin 81 mg at 11:26 AM, Metoprolol Tartrate at 11:27 AM, Apixaban at 11:26 AM, and Ferrous Sulfate at 11:27 AM. Review of R4's progress notes of July 26 and 27, 2024, showed there was no notification to the prescriber regarding the late administration of scheduled medication. Page 1 of 2 146194 146194 08/07/2024 Thrive of Fox Valley 4020 E New York Street Aurora, IL 60504

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On August 6, 2024, at 11:05 AM R4's wife stated she is at R4's bedside every day, all day and she is concerned that R4's medications are administered late. R2's EMR (Electronic Medical Record) showed R2 was most recently admitted to the facility on [DATE], had previously been in the facility on January 6, 2023, and discharged [DATE]. R2 had multiple diagnoses including spinal stenosis lumbar region, other disorders of the peripheral nervous system, diabetes type 2, morbid obesity due to excess calories, malignant neoplasm of the colon, hidradenitis suppurativa, polyneuropathy and unspecified asthma. R2's MDS (Minimum Data Set) dated 8/2/2024 showed R2 to be cognitively intact. On August 3, 2024, at 2:20 PM, R2 stated she had a concern that sometimes her medication is given to her later than scheduled, especially her medication for pain. R2's Medication Administration Audit report, dated July 28, 2024, showed R2 scheduled medication for 9:00 AM included Tylenol Codeine tablet 300-30 mg give one tablet by mouth every 12 hours. R2's Medication Audit report showed R2's Tylenol codeine tablet scheduled to be given at 9:00 AM was administered at 1:25 PM. Review of R2's progress note showed there was no note indicating the prescriber had been notified of the medication being administered late nor guidance when to administer the next scheduled dose, as the order showed medication to be administered every 12 hours. On August 6, 2024, at 10:44 AM, V2 (Director of Nursing/DON) stated it is the expectation for nurses to contact the prescriber when medications are not available from the pharmacy or administered late. The Facility's policy titled Medication Pass Times, dated revision May 2023, showed Medications are administered according to a standard schedule, resident needs and physicians' orders .1. The following is a list of scheduled medication times .person centered liberalized medication pass windows .AM: 7AM - 10 AM .the medication pass times below will be utilized according to provider orders .a. QD (every day/daily) 9:00 AM. 146194 Page 2 of 2