Inspection·March 27, 2024

F 0759 Level of Harm - Minimal harm or potential for actual harm The Medication Administration Policy, dated 3/24, fails to document what the policy is for unavailable medications. 2. R7's admission Record, print date of 3/26/24, documents that R7 was admitted on [DATE] with diagnoses of Dysphagia and Gastrostomy Status. Residents Affected - Few R7's Physician Orders, dated March 2024, documents, Enteral Feed every shift Enteral - Check Residuals before beginning a feeding and before medication administration. If Greater than 100 cc (cubic centimeter), HOLD Feedings and Recheck in 1 HR (hour). If not resolved, CALL MD (Medical Doctor) start date of 8/8/23. Enteral Feed every shift Enteral - Check Tube Placement before Feeding, Flush and Meds (Medications) start date of 8/8/23. May crush Pharmaceutically acceptable Medications or open capsule and mix with food or liquid, Start date of 8/7/23. R7's Physician Orders, dated March 2024, documents, Aspirin 81 mg Oral Tablet Chewable. Give 81 mg enterally one time a day for heart health, Clopidogrel Bisulfate Oral Tablet 75 mg Give 75 mg enterally one time a day for heart health, Lisinopril Oral Tablet 10 mg Give 10 mg enterally in the morning for high cholesterol, Metoprolol Tartrate Oral Tablet 25 mg Give 25 mg enterally every morning and at bedtime for hypertension, Sertraline HCL Oral Tablet 100 mg Give 1 tablet via G-tube in the morning related to Depression, Lizanidine Oral Tablet Give 4 mg enterally every morning and at bedtime for muscle relaxer, and Valproic acid Oral Solution 250 mg/ 5 ml Give 10 ml enterally every 8 hours for seizures. The facility policy Medication Administration - Gastrostomy or Nasogastric Tube, dated 11/2023, documents, Gastrostomy Tube: Aspirate to visually verify stomach contents. It continues, 9. After verifying placement, connect a 60 ml (milliliter) piston to the end of enteral tube and flush with approximately 30 ml of tap water via gravity prior to medication administration. 11. Administer medication: Use liquid preparations whenever possible. Check with the pharmacist if in doubt about availability of medication in liquid form or whether tablets are crushable. Enteric coated medications, sublingual tablets, and sustained release medications should not be crushed. If more than one medication is being given at a dosing time, administer each medication separately, flushing the tube with approximately 10 ml of tepid water between medications, or enough to clear the tubing. Tablets will be finely pulverized and dispensed well in tepid water. 12. Following administration of all medications, flush the tube via gravity with approximately 30 ml of tap water or the prescribed flush amount. On 3/26/24 at 8:30 AM, V15 prepared the following medications for R7; Valproic Acid 250 mg/ 5 ml, 10 ml liquid poured into a small medicine cup, Aspirin 81 mg chewable, Lisinopril 10 mg, Metoprolol 25 mg, Sertraline 100 mg, Lizanidine 4 mg, and Clopidogrel 75 mg . V15 crushed all pills together and put them all into a small disposable water cup. At 8:35 AM, V15 took R7 to his room. V15 poured 300 ml of Jevity 1.2 into a disposal medication syringe container that is used to administer medication through a Gastrostomy tube (G-tube). She then added 50 ml of water to the container. V15 stated, This stuff is so thick you have to thin it out. V15 then added approximately 30 ml of water to the cup that holds all the crushed medicines. V15 auscultated placement of the G-tube. V15 attached the disposal medication syringe to the G-tube, V15 poured Jevity into the syringe once it drained, she filled the syringe again this time adding the Valproic acid to the syringe. Once that had drained, she added more Jevity until it was gone. The last syringe full of Jevity once it got down to about 20 ml, she added half of the medicine water mixture. Once that had drained, she poured the rest of the medicine water mixture. The bottom of the cup had crushed medication remaining. V15 took a little water swished the cup around and poured it into the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 2 of 3 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 145928 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Jacksonville 1021 North Church Street Jacksonville, IL 62650 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few syringe. Some of the crushed medication remained in the bottom of the cup. V15 removed the syringe from the G-tube and stated she was finished. V15 did not flush the G-tube with water. On 3/26/24 at 9:00 AM, V25, Assistant Director of Nurses, was informed of V15 mixing all the crushed medications and giving them together, leaving crushed medication in the bottom of the cup, and no water flush after, V25 stated, Well, it's not good. V15 just came back from medical leave, and she is a little scattered. V25 did not know why R6's medications were not available. On 3/27/24 at 3/27/24 at 1:55 PM, V15, LPN, stated that she was unaware the medications could not be crushed, diluted in water altogether, and then given all together. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145928 If continuation sheet Page 3 of 3