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). (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: 145619 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 145619 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Lake Storey 1250 West Carl Sandburg Drive Galesburg, IL 61401 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)