Health inspection·April 11, 2025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and implement gradual dose reductions (GDR's) as recommended by the pharmacist and/or document a rationale for contraindication for 1 (R13) of 5 residents reviewed for unnecessary psychotropic medications in the sample of 34. Findings Include: R13's Face Sheet documented R13 was admitted to the facility on [DATE] and included the following diagnoses: acute and chronic respiratory failure, undifferentiated schizophrenia, type 2 diabetes mellitus, convulsions, hepatic failure, depressive disorders, chronic obstructive pulmonary disease, essential hypertension, sleep apnea, heart failure, atrial flutter, generalized anxiety disorder, and gastro esophageal reflux disease. R13's MDS (Minimum Data Set) dated 03/03/2025 documented R13 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R13 is cognitively intact. R13's Physician Order Report with a print date of 04/10/2025 documented an order for Effexor XR (extended release) 150 milligrams (mg) by mouth daily for depressive symptoms with a start date of 07/30/2023, clozapine 100mg by mouth every night for schizophrenia with a start date of 03/22/2023, and buspirone 10 mg by mouth daily for generalized anxiety with a start date of 09/23/2023. R13's Care Plan has a focus are of: Cognitive Loss / Dementia: Problem: R13 currently goes to senior renewal. R13 has the dx of schizophrenia, dependent personality disorders, depression and anxiety. R13 is currently taking anti-psychotic, antidepressant and antianxiety. R13 does not take criticism will [sic]. R13 lacks self-confidence. when a problem comes up, she likes to look for support to make a decision. R13 is independent with her activities of daily living. For the most part R13 is alert and oriented and able to let needs known. Documented interventions are R13 goes to senior renewal program weekly, take medications and record effectiveness, allow resident to express feelings, do not confront, argue against, or deny residents thoughts, and do not judge resident in any way. R13's Point of Care History with a print date of 04/10/2025 documented behaviors monitored are verbal expressions of distress, sleep cycle issues, apathetic, anxious, or sad appearance, mood, or loss of interest with a date range of 3/11/25 - 4/10/25, and documented behaviors did not occur for these dates. The consultant pharmacist's Note to Attending Physician/Prescriber documented a Medication Regimen Page 1 of 4 145388 145388 04/11/2025 Helia Healthcare of Olney 410 East Mack Olney, IL 62450

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review (MRR) dated 10/28/24 and stated, This resident's order noted below is due for review and dose reduction attempt. Please document current mental and behavior status; review the new dose recommended below or provide detailed reason(s) that a dose reduction is not indicated .Current order: Clozaril (clozapine) 100 mg at bedtime for schizophrenia .Date started: 12-6-2016 .Recommend to change to: 75 mg at bedtime. Under the section titled, Physician/Prescriber Response, the boxes for agree, disagree, and other are left blank, along with the space to explain the rationale, the physician/prescriber's signature, and date. Progress Notes in R13's medical record authored by V2 (Director of Nursing/DON) documented the following: 10/14/24: GDR (gradual dose reduction) requests for buspirone, clozapine and Effexor sent to psych NP (Nurse Practitioner). 10/17/24: GDR requests from 10-14 forwarded to V14 (NP) per request of V16 (NP). 12/16/24: GDR request for Clozaril emailed to (V14) psych NP, per request of V16 (NP). 02/27/25: GDR requests sent to V16 (NP) for buspirone, clozapine, and Effexor xr. 03/11/25: GDR requests for buspirone, Clozaril, and Effexor ER emailed to (V14) psych NP, per request of V16. 04/09/25: Reached back out to (V14) regarding GDR requests for Buspar, clozapine, and Effexor. Last correspondence was 3/11/25, where she stated she would review them. Email communications between V2 (DON) and V14 (NP) document the following: 10/17/24 documented V2 emailing R13's gradual dose reductions to V14. 12/16/24 documented V2 again emailing R13's GDR requests to V14. 03/11/25 documented another request from V2 for V14 to review R13's GDR requests. Return correspondence from V14 on that same day documented V14 replied Yes . 04/09/25 documented V2 emailing V14 to follow up on R13's GDR's, noting, We have state in for annual survey this week, so I was trying to get everything in order. Have you had a chance to review them yet? with V14 replying she would attempt to stop by on 04/09/25. On 04/10/2025 at 9:20 AM, V2 (DON) stated she does not know why it takes V14 (NP) so long to respond to the gradual dose reductions. V2 stated that V14 has been contacted multiple times regarding R13's gradual dose reduction. V2 stated that she has tried to stress the importance of V14 responding to the gradual dose reductions and that V14 has replied that she will review them, but she never does. V2 stated that R13 has no behaviors, and she feels that a gradual dose reduction is appropriate. On 04/11/2025 at 9:36 AM, V15 (Registered Nurse) stated R13 does not have any behaviors. V15 stated she is pleasant and gets along well with staff and other residents. On 04/11/2025 at 10:00 AM, V2 stated that V14 has not responded to any of the gradual dose 145388 Page 2 of 4 145388 04/11/2025 Helia Healthcare of Olney 410 East Mack Olney, IL 62450

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reductions that have been emailed to her. V2 stated V14 has never responded to any of the requests. V1 (Administrator) was also present and stated that V1 emailed V14 on 04/09/25 at 6:00 PM trying to correspond with V14 about the gradual dose reductions. V1 stated that V14 has not responded. According to WebMD's drug interaction checker at https://www.webmd.com/interaction-checker/default.htm, there is a potential for serious interaction between venlafaxine (Effexor XR) and buspirone (Buspar) and regular monitoring by your doctor is required or alternate medication may be needed. Venlafaxine and buspirone both increase affecting serotonin levels in the blood. Too much serotonin is a potentially life-threatening situation. Severe signs and symptoms include high blood pressure and increased heart rate that led to shock. In addition, Venlafaxine and Clozapine document a significant interaction possible and close monitoring by your doctor is required. Facility policy titled Psychotropic Medication Use with a date of December 2018 documented It is the policy of (company name) that all residents receiving psychotropic medications, be monitored to ensure the least amount of medication is given to treat the diagnosis. This is accomplished through tracking behaviors and effectiveness of interventions, monitoring for side effects, reviewing data at least quarterly and dosage reduction attempt at least one quarter annually 2. Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs .8. The Psychoactive Medication Review (Quarterly) will be completed at least quarterly to combine the data on one form for review 9. The physician/psychiatrist will order a reduction in medication, as indicated, or document the need for continuing the current dosage, at least quarterly. 145388 Page 3 of 4 145388 04/11/2025 Helia Healthcare of Olney 410 East Mack Olney, IL 62450

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure a medication cart was locked and its keys were not accessible to 4 (R31, R42, R58 and R66) of 4 confused ambulatory residents reviewed for safe and secure storage of medications in the sample of 34. On 04/09/25 at 08:05 AM, V5 (Registered Nurse/RN) was observed passing medications on B Hall. V5 prepared medications for a resident and entered the residents room, leaving the medication cart unlocked and the cart keys on top of the cart, and out of V5's visual control. On 04/09/25 at 08:13 AM, V5 prepared medications for another resident and left the cart keys on top of the cart and out of V5's visual control. During these observations, there were residents or staff near the cart. On 04/10/25 at 03:01 PM, V2 (Director of Nurses/DON) confirmed the medication cart is to be kept locked and its keys in possession of the nurse passing medications. The facility's Storage of Medications Policy dated 5/1/18 documented Medications and biologicals are stored safely, securely, and properly, following manufacturers recommendations or those of the supplier. The medication supply is accessible only by licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (are) permitted to access medications. Medication rooms, carts, emergency kits/boxes, and medication supplies are locked when not attended by persons with authorized access. An undated policy for Personnel Authorized to Handle Medications in the Facility stated, Licensed nursing personnel who administer medications have authorized access to medication storage areas in the facility. Consistent with their scope of practice, licensed nurses may transcribe and transmit orders to the pharmacy(ies), receive and store medications, and have possession of the keys to all drug storage areas in the facility. Keys to medication storage areas are under the control of licensed personnel only. The facility provided a list dated 4/11/25 which documented R31, R42, R58, and R66 as being confused, ambulatory residents living at the facility. 145388 Page 4 of 4