Health inspection·August 18, 2022

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. Based on observation, interview, and record review, the facility failed to attempt an annual GDR (Gradual Dose Reduction), document clinically indicated diagnoses and behaviors, and implement non-pharmacological interventions for the use of anti-psychotic medications for two of three residents (R3, R40) reviewed for anti-psychotic medication use with the diagnosis of Dementia/Alzheimer's in the sample of 24. Findings include: The facility's Gradual Dose Reduction (GDR) of Psychotropic Drugs policy dated 2-1-22 documents, Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Reducing the need for and maximizing the effectiveness of medications shall be considered for all residents who receive psychotropic drugs. Therefore, dose reductions and behavioral interventions are part of medication management. This policy pertains to gradual dose reductions. Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility will attempt a GDR in two separate quarters. 3. After the first year, a GDR will be attempted annually, unless clinically contraindicated. 1. R3's admission Orders dated 12-31-20 document, Seroquel 25 mg (milligram), two tablets every night for diagnoses of Depression and Delusions. R3's Physician's Order Sheets (POS's) dated 12-31-20 through 8-16-22 document R3 has received Seroquel 25 mg two tablets every night and has not had a GDR (Gradual Dose Reduction) attempt. These same POS forms document R3 has diagnoses of Major Depression, Delusional Disorder, Alzheimer's Disease with Late Onset, and Major Depression. R3's MDS (Minimum Data Set) Assessments dated 2-3-22, 5-6-22, and 8-5-22 document R3 receives an anti-psychotic medication daily and does not have physical, verbal, or other behavior symptoms. R3's Medication Administration Records (MAR) dated 6-1-22 through 8-16-22 document R3 has had no hallucinations and has only had delusions on two days during this time. These same MARs do not include documentation of non-pharmacological interventions used along with effectiveness of these interventions to treat R3's delusions. On 8/15/22 at 10:06 AM, R3 was walking up and down the 500 hallway. R3 had no adverse behaviors at this time and was easily re-directed by V5 (CNA\Certified Nursing Assistant). Page 1 of 2 145619 145619 08/18/2022 Allure of Lake Storey 1250 West Carl Sandburg Drive Galesburg, IL 61401

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 08/15/22 at 10:10 AM, V5 (CNA) stated, (R3's) only behavior is wandering and trying to exit the facility. (R3) never has verbal or physical behaviors that I am aware of. On 08/16/22 at 10:48 AM V2 (Director of Nursing) stated, (R3) has never had a GDR attempt of her Seroquel since (R3) was admitted . The facility has not had a psychiatrist to see the residents in a while and (V6/R3's Physician) does not like to mess with anti-psychotic medications if he was not the one to prescribe them. (R3) takes Seroquel for wandering and non-compliance with cares and re-direction. I know those behaviors are not justification for the use of Seroquel and we (the facility) should have attempted to reduce (R3's) Seroquel. There is also no documentation of non-pharmacological interventions attempted to treat (R3's) behaviors. 2. R40's current Physician Order Sheets dated 7/31/22 through 8/16/22, documents R40 receives Olanzapine Tablet 2.5mg (milligrams) four times weekly for Psychosis. This same POS documents R40 has diagnoses of Dementia with behavioral disturbances. R40's MARs dated 6/1/22 through 8/15/22 document Antipsychotic Behavior Tracking of document number of episodes of mood swings and suspicious behaviors every shift. This behavior tracking does not include any behaviors of harm to herself or harm to other residents, or any non-pharmacological interventions used along with effectiveness of these interventions. The behavior tracking for mood swing episode documents R40 has not had any of these behaviors. R40's MDS (Minimum Data Set) Assessments dated 4/26/22 and 7/26/22 document R40 receives an anti-psychotic medication daily and does not have any physical, verbal, or other behavior symptoms. On 8/15/22 at 11:30 am., R40 was sitting in her wheelchair exhibiting no adverse behaviors. On 8/16/22 at 11:35AM, V7/Registered Nurse stated, (R40) does not have behaviors of harm to herself or toward other residents. On 8/16/22 at 1:30 PM, V2/Director of Nursing stated, R40 did have behaviors in the past verbally and physically towards staff, but has had a stroke and does not have these behaviors. V2 also stated, they have not been tracking behaviors of aggression towards herself or others and there is no documentation of any harmful behaviors towards herself or other residents. 145619 Page 2 of 2