Health inspection·May 12, 2025

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review the facility failed to verify placement of a gastric feeding tube prior to instilling flush and medications and failed to flush the tube between medications for one resident (R1) of three residents reviewed for medication administration in a sample list of four. Findings Include: The facility's policy Medication Administration -Gastrostomy or Nasogastric Tube reviewed 8/3/20 states Check tube for proper placement: Aspirate to visually verify stomach contents. Gastric fluid normally appears clear or yellow with mucus or may appear milky if residual remains from previous feeding. Aspirated contents must be returned to the stomach to maintain ph (Acid Base Balance), fluid and electrolyte balance. This policy also states if more than one medication is being given at a dosing time, administer each medication separately, flushing the tube with approximately 10 milliliters of tepid water between medications, or enough to clear the tubing. Tablets will finely pulverize and disperse well in tepid water. On 5/8/25 at 11:45AM V7, RN (Registered Nurse) administered R1's Entacapone Oral Tablet 300 MG and Sinemet Oral Tablet 25-100 MG six tablets via R1's gastrostomy tube. V7 crushed the two separate medications and dissolved each in a separate cup with water. V7 entered R1's room. V7 accessed R1's feeding tube but failed to verify placement prior to placing the syringe in the tube. V7 also failed to flush the tube with water between the two medications. V7 then flushed the tube with water, removed the syringe and closed the open tube. On 5/12/25 at 10:00AM V7 stated I should have aspirated the gastrostomy tube for stomach contents before I gave the medications to (R1) yesterday and I should have flushed the tube between the medications. Page 1 of 3 145183 145183 05/12/2025 Goldwater Care Danville 620 Warrington Avenue Danville, IL 61832

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer a medication according to manufacturer's directions and failed to utilize PRN (as needed) doses for one resident (R1) of three residents reviewed for medications in a sample list of four residents. This failure caused R1 to receive insufficient dose of medication which lead to increasing signs and symptoms of Parkinson's Disease which caused R1 to be fearful and suffer psychosocial harm. Residents Affected - Few Findings Include: R1's Care Plan updated 4/17/25 includes the following diagnoses: Parkinson's Disease without Dyskinesia, Functional Quadraplegia, Chronic Obstructive Pulmonary Disease, Type II Diabetes Dysphagia, and Dysphasia with a gastrostomy tube. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and is dependent on staff to complete Activities of Daily Living (ADLs). R1's current physician's orders include an order for Apomorphine HCl (Apokyn)Solution Cartridge 30 MG/3ML Inject 0.6 ml subcutaneously every two hours as needed for freezing or slowness/inability to speak related to Parkinson's Disease. Can be given up to two times two hours apart. Maximum of five times daily and Inject 0.6 ml subcutaneously before meals for freezing episodes related to Parkinson's Disease. Give one hour prior to meals. The manufacturer's directions for administering Apokyn state IMPORTANT - Prior to each injection, it is important that the Apokyn Pen be properly primed. For a new Apokyn Cartridge (1 that has not been used before), repeat the priming procedure described on the next page (Steps 8-9) 3 or 4 times to make sure all the air has been removed from the needle and cartridge. For an Apokyn Cartridge you have used before (1 that has been previously primed), repeat the priming procedure described on the next page (Steps 8-9) 1 time to make sure all the air has been removed from the needle and cartridge. Step 8. You must prepare (prime) the Apokyn Pen for use before injecting the medicine. To prime the Apokyn Pen, set the dose by turning the dose knob to 0.1 ml. This is important so you can get rid of any air bubbles in the cartridge. Step 9. Remove the inner needle shield. Remember, do not let the needle touch anything. With the needle pointing up, firmly push the injection button in as far as it will go and hold for at least 5 seconds. A small stream of medicine must come out of the end of the needle. If it does not, reset the dose by repeating Step 8. Repeat these steps (Steps 8-9) until a small stream of medicine comes out the end of the needle. When medicine comes out of the end of the needle, the Apokyn Pen is primed for injection and ready to use. On 5/8/25 at 11:30AM V7, RN (Registered Nurse) administered R1's Apokyn. V7 did not prime the needle. When asked if the needle needed primed V7 stated As far as I know we have never primed the needle. V7 verified she regularly works the day shift on the hall where R1 resides. On 5/8/25 at 11:35AM (R1) was seated in a high-backed reclining chair in her room. (R1) was able to speak softly and slowly at this time. (R1) stated when I freeze up like that I am scared to death. I can't talk, but I know what is going on. All I can really do is roll my eyes up to the ceiling to let them know I am in here. I don't think all the staff know this is my only communication. If I get 145183 Page 2 of 3 145183 05/12/2025 Goldwater Care Danville 620 Warrington Avenue Danville, IL 61832

F 0760 the shot I am able to move and talk a lot sooner. Level of Harm - Actual harm On 5/8/25 at 1:00PM V5, R1's family member stated (R1) gets the Apokyn to help her avoid or shorten the time of episodes where her muscles freeze and (R1) is unable to move, swallow, or speak. This is very frightening to (R1). I have cameras in R1's room so I can see that (R1) is taken care of. (R1) is to get her shot an hour prior to meals and that doesn't happen always. (R1) is also able to get up to two additional doses for freezing episodes and that is often not given. This is causing more frequent and longer episodes. V5 stated according to her camera on 5/5/25 (R1) had an episode from 12:00PM until 3:48PM and again from 5:42PM until 12:00AM. R1's Medication Administration Record (MAR) does not document any PRN doses of Apokyn were given on 5/5/25. Residents Affected - Few On 5/12/25 at 9:54AM V13 Registered Pharmacist for the facility's contracted provider stated the manufacturer's direction should definitely be followed when administering any medication. If the needle isn't primed the resident is definitely not receiving the correct dose of the medication especially when the dose is a small amount. Not receiving the correct dose as ordered could potentially affect the efficacy of the medication. The facility's policy Subcutaneous Injection revised 2/2/18 fails to address the necessity of priming the needle when utilizing multidose cartridge pens. 145183 Page 3 of 3