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, observation, and record review, the facility failed to provide the physician ordered pain medication
for 1 of 3 residents (R3) reviewed for pharmacy services in the sample of 3.
Findings include:
R3's admission Record Form, undated, documented R3 was admitted on [DATE] with diagnosis of Infection
and Inflammatory reaction due to internal Left knee prosthesis.
R3's Minimum Date Set, dated 1/30/24, documents R3 is cognitively intact.
R3's Physician Order, start date of 1/23/24, documents, Oxycodone-Acetaminophen Oral Tablet 5-325 MG
(Oxycodone w (with)/ Acetaminophen) Give 2 tablet by mouth every 4 hours as needed for chronic pain.
R3's Nurse's Note, dated 3/25/2024 08:58, documents, Nurses Note Late Entry: Narrative: Placed an order
to send oxycodone stat (immediately).
R3's Nurses Note, dated 3/26/2024 09:00, documents, Nurses Note Narrative: per pharmacy oxycodone
will be out in am delivery resident's pain assessed and an alternative prn (as needed) for pain offered.
R3's Medication Administration Record, dated March 2024, documents that R3 did not receive any
Oxycodone - Acetaminophen tablets from 3/23/24 - 3/25/24. R3 did receive a dose of Oxycodone Acetaminophen on 3/26/24 at 5:18 PM.
On 4/1/24 at 8:50 AM, R3 stated he has an antibiotic spacer in his left knee and the doctors want to cut his
leg off, but he does not want to lose his leg. He stated there is a wound on the left leg that hurts. R3 stated
the right leg is broken and has been for 2 years. He pulled the covers back and the right thigh was
extremely swollen. R3 said he must get up with a (full mechanical lift). R3 stated, Last Friday I ran out of my
pain medication. I did not get a dose until Tuesday morning around 9:30 AM. They said that they didn't order
it and when they did it never came in. I usually run out at the end of the month. The 0-10 pain scale was
explained to R3 and that 10 is the worst pain that he has ever felt. R3 stated, My pain was a 30 for those 4
days. It hurt so bad I couldn't move.
On 4/1/24 at 1:17 PM, V3, Licensed Practical Nurse (LPN), stated she did take care of R3 over the
weekend of 4/23/24 and 4/24/24. V3 stated, He was out of Oxycodone, and I sent his prescription to
(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:
145160
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
145160
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/01/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care on the Hill
555 West Carpenter
Springfield, IL 62702
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the pharmacy to get filled. I offered R3 Tylenol, but he did not want that. He said that he was in pain, but he
was acting his normal self-telling jokes and stuff. I did not see any obvious signs of pain.
On 4/1/24 at 1:25 PM, V5, LPN, stated, I came in Monday morning and the night nurse (V7) told me R3
was out of his pain medication because he needed a new prescription. She (V7) had put the request in for
the Nurse Practitioner and it should be taken care of today. I went in and told (R3) all of this. He said he was
in pain, but he was acting like he does all the time. I did not see physical signs of pain.
On 4/1/24 at 10:45 PM, V2, Director of Nurses, stated, (R4's) insurance advocate came and told me on
Monday 3/25/24 that (R4) was out of pain medication. I told her I did not know that so I would look into it. I
went and spoke to his nurse (V5), and I told her to give him some Tylenol since he does have that. I went
and ordered the medicine STAT (immediately) from pharmacy.
On 4/1/24 at 1:10 PM, V2 stated the prescription that was sent to pharmacy on 3/23/24 ended up not
having any more refills on it so R3 needed a new prescription written and sent to pharmacy. V2 stated, That
is what the problem was. On the 25th the order was put in STAT, but our pharmacy has a cut off time that is
why it didn't come until the 26th. (R3) was saying he was having pain, but he always says that. I see him
multiple times a day. He sits right outside of my office, and he never complained to me about his pain. He
was acting like his normal self.
On 4/1/24 at 2:05 PM, V1 stated she has been looking for the pharmacy policy but it unable to locate it at
this time. V1 stated if the nurses run out of a medication, they should put in for a refill and continue to
contact pharmacy if it is not delivered timely.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145160
If continuation sheet
Page 2 of 2
