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 Page 1 of 2 145136 145136 11/08/2024 Arcadia Care Auburn 304 Maple Avenue Auburn, IL 62615

F 0760 Medication Pass which allows nurses to pass morning medications between 6:00 AM and 11:00 AM. Level of Harm - Minimal harm or potential for actual harm The Facility's Liberalized Medication Administration Policy revised 4/2022 documents medications should be administered to residents in a safe manner, but in a way that correlates with their daily activities and natural schedules. Residents Affected - Few The Facility's Medication Administration Policy revised 1/2015 documents medications must be administered in accordance with a physician's order, e.g. the right resident, right medication, right dosage, right route, and right time. 145136 Page 2 of 2