Health inspection·November 8, 2024

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer anti-hypertensive/cardiac medications at safe intervals of time for 2 of 3 residents (R2, R3) reviewed for medications errors in the sample of 4. Residents Affected - Few Findings include: 1-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, stage 4 chronic kidney disease, congestive heart failure, and essential primary hypertension. R2's Physician Order dated 6/24/24 documents Carvedilol Oral Tablet, 25 milligram (mg) tablet, give one tablet by mouth two times daily for hypertension. R2's Medication Administration Audit Report for 11/4/24 documents R2 received 6:00 AM dose of Carvedilol at 11:32 AM and 4:00 PM dose at 3:52 PM. On 11/8/24 at 9:40 AM, V10, Licensed Practical Nurse (LPN), stated R2 did not get her medication until later in the day on 11/4/24 because she sleeps in late. V10 stated she did not communicate to the next nurse that it was given late. 2-R3's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including pulmonary heart disease, heart failure, and essential primary hypertension. R3's Physician Order dated 5/24/24 documents Carvedilol Oral Tablet, 25 mg tablet, give one tablet by mouth two times a day for hypertension. R3's Medication Administration Audit Report for 10/27/24 documents R3 received 6:00 AM dose of Carvedilol at 1:14 PM and 4:00 PM dose at 4:32 PM. On 11/8/24 at 9:40 AM, V10 stated she was unsure why R3's medication was given late on 10/27/24, but the Facility only has three nurse aids on morning shift and she often helps them out before passing medications. On 11/7/24 at 3:18 PM, V9, Medical Director, stated Carvedilol should not be given within three or four hours of each other, because it can cause hypotension (low blood pressure) and bradycardia (slow heart rate). On 11/8/24 at 8:50 AM, V2, Director of Nursing (DON), stated the Facility follows a Liberalized (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: 145136 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 145136 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Auburn 304 Maple Avenue Auburn, IL 62615 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)