Arc At Streator

findings include:R1's current care plan dated 2/6/26 showed R1 was severely cognitively impaired

summary report showed R5 had diagnoses including epilepsy (seizure disorder) and chronic pain.

The report showed the following medication orders for R5:1.Carbamazepine (anticonvulsant drug) 400 mg (milligrams), give one tablet at bedtime daily.2.Phenobarbital (anticonvulsant drug) 97.2 mg, give one tablet at bedtime daily.3.Tramadol (opioid pain medication) 50 mg, give one tablet three times a day for pain.R1's progress notes dated 2/11/26-2/12/26 showed on 2/11/26 at 8:20 PM, V6 (Licensed Practical Nurse/LPN) administered R5's Carbamazepine 400 mg, Phenobarbital 97.2 mg, and Tramadol 50 mg to R1 in error.

The notes showed R1's physician and Poison Control were notified immediately of the error.

Per recommendation of Poison Control and the physician, R1 was to remain in the facility with orders to closely monitor R1, however, R1's family requested R1 be sent to a local hospital for an evaluation due to the error.

The notes showed R1 was evaluated at the hospital and discharged back to the facility approximately eight hours later in stable condition.On 2/27/26 at 10:15 AM, V6 (LPN) stated on 2/11/26, she prepared R1 and R5's evening medications by putting each resident's medications in separate medication cups. V6 stated she was abruptly called into another resident's room, so she quickly locked R1 and R5's medications, in their individual cups, in the medication cart, and went to assist the resident. V6 stated when she returned to the medication cart, she grabbed R5's medication cup and administered R5's medications to R1 in error. V6 stated, I was in a hurry. I didn't check to make sure I had the right medications for (R1). V6 stated, (R1) was sleepy when he left in the ambulance but that was normal for him at that time of the day.

His mentation had not changed.On 2/27/26 at 9:40 AM, V5 (R1's Physician) stated, While (R5's) medication could have caused (R1) to be sedated, this incident is something we could have monitored in the facility. (R1) did not need to go to the hospital. We only sent him out because his family said to.

They observed him for a while in the hospital and sent him back.On 2/27/26 at 12:07 PM, V3 (Assistant Director of Nursing) stated nurses are to double check medications before administration to verify the medication is the right drug, right patient, right dose, right time, and right route. V3 stated nurses are to administer medications to each resident, immediately after preparing their medications.

The facility's Medication Administration policy dated January 2026 showed, Medications must be administered in accordance with physician's order, e.g., the right resident, right medication, right dosage, right route, right time.

Medications may not be pre-poured, e.g., only prepare and administer medications for one resident at a time.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE