Inspection·July 28, 2025

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Based on observation, interview, and record review the facility failed to follow a resident's prescribed diet for 1 of 3 residents (R3) reviewed for prescribed diets in the sample of 6.Findings include:On 7/26/25 at 11:55 AM, R2 was sitting in his wheelchair at the dining room table with his lunch tray in front of him. R2 had ham, mixed vegetables, creamed corn, dinner roll, butter, chocolate cream pie, water, and apple juice. R2 stated he just eats and drinks whatever they put in front of him. R2 confirmed that he was drinking apple juice that was given to him. The meal ticket next to R2 showed he was to have a carbohydrate controlled low concentrated sweet diet (LCS), regular texture, thin liquids and sugar free hot chocolate. V5 (Certified Nursing Assistant/CNA) came over to tie R2's clothing protector and his meal ticket was shown to her. V5 stated she just looks at the name on the meal ticket and gives the resident what is ordered. V5 stated the cook is the one that looks at the ticket and puts the food and beverages on the tray. On 7/26/25 at 12:10 PM, V4 (Dietary Manager) stated residents are served food based on what is on their meal tickets. V4 stated R2's wife and physician prefer he have sugar free drinks. V4 stated on today's dietary flowsheet residents on LCS diets can have the pie and dinner roll but at dinner when the sherbet is served, they would get mandarin oranges. V4 stated the dietary flowsheet shows how many and the types of carbohydrates they can have per day.The Dietary Flowsheet for the day of 7/26/25 showed for residents on Carbohydrate Controlled/LCS diets for lunch they can have brown sugar glazed ham, creamed corn, vegetable medley, dinner roll with margarine, chocolate cream pie and a diet beverage. The only difference between the regular diet and LCS is the beverage for lunch. LCS say diet beverage and the regular diet just said beverage.On 7/26/25 at 1:15 PM, V4 stated she asked the cook why she gave R2 apple juice, and the cook stated because it was high in fiber. V4 stated she did not know where the cook pulled that from. V4 stated R2 should not have been given the apple juice. V4 stated it was not an appropriate choice for R2 especially since his wife and doctor want him to have sugar free options.On 7/26/25 at 5:20 PM, V1 (Administrator) stated R2 is on the LCS diet related to his neurological disorder. R2's wife likes his weight to be maintained, and this diet helps with his weight and disorder because when he gains weight his disorder is worse. The Face Sheet dated 7/26/25 for R2 showed diagnoses including cerebral infarction, sleep apnea, multifocal motor neuropathy, polyneuropathies, obstructive sleep apnea, allergic purpura, and osteoarthritis. The Physician Order Summary dated 7/26/25 for R2 showed a no added salt/low concentrated sweet diet.The Care Plan for R2 dated 3/26/25 showed he has a potential risk for altered nutritional status related to diagnoses of cerebral vascular accident, multifocal motor neuropathy, and neuropathies. R2 is on a no added salt/carb-controlled diet and no additional sweets. Follow the recommendations of the dietician. The Dietary Note dated 3/26/25 for R2 showed no added salt/carb-controlled diet, 2000 calories, and no additional sweets.The facility's Diet Orders policy (8/2023) showed, all diet orders are documented in the health record by the physician, or Registered Dietitian (where allowed). In some cases, the (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: 145968 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 145968 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Arcadia Care Kewanee 144 Junior Avenue Kewanee, IL 61443 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)