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
observation, interview and record review the facility failed to provide an appropriate indication for use of an
antipsychotic medication for two residents (R31, R33) with diagnosis of dementia of five residents reviewed
for unnecessary medications in the sample of 22.
Findings include:
Facility Policy/Use of Psychotropic Medication dated 2023 documents:
The indications for use of any psychotropic drug will be documented in the medical record.
Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall
be included in the documentation.
Facility Policy/Antipsychotic medication Use dated/revised 2021 documents:
Residents will only receive antipsychotic medications when necessary to treat specific conditions for which
they are indicated and effective.
Diagnoses alone do not warrant the use of antipsychotic medication.
For enduring psychiatric conditions, antipsychotic medications will not be used unless behavioral symptoms
are:
not due to psychological stressors (e.g., loneliness, taunting, abuse), or anxiety or fear stemming from
misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where
he/she lives or inability to find clothes or glasses) that can be expected to improve or resolve as the
situation is addressed.
Antipsychotic medications will not be used if the only symptoms are one or more of the following:
Uncooperativeness
Wandering
Restlessness
(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 3
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
07/14/2023
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)
F 0758
Mild Anxiety
Level of Harm - Minimal harm
or potential for actual harm
Impaired Memory
Residents Affected - Few
1) Current Physician's Order Report Summary indicates R31 is [AGE] years old with diagnoses that include
Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and
Anxiety; Brief Psychotic Disorder (4/4/23); Mild Dementia with Behavioral Disturbance (10/1/22);
Unspecified Psychosis (3/17/20).
Order Summary indicates R31 has orders for Olanzapine (antipsychotic) 2.5mg (milligrams) every bedtime
increased on 4/5/23 related to Unspecified Psychosis (4/23/23).
Informed Consent for Psychotropic Medication indicates consent for Olanzapine Recommended Daily Total
Dosage Range 5mg - 10mg, Anticipated Dosage Range 5mg with Reason for Use of Medication Psychosis,
Mood Stabilizer on 2/14/19. Consent does not indicate specific, target behaviors.
Behavior Monitoring and Interventions Report dated June/July 2023 indicates R31 continues to exhibit
physically aggressive behaviors with care, expresses frustration/anger at others, attempts to scratch, kick
and hit.
On 7/13/23 at 9:45am V10, CNA (CNA) stated R31 pinches, scratches and hits anytime she needs to be
changed, and it is worse with showers. V10 stated R31 is calm and has no behaviors except when staff are
providing personal care.
Telemedicine Psychiatric Periodic Evaluation dated 4/4/23 indicates, (R31) has had more psychotic and
aggression symptoms with staff of recent.
Evaluation does not indicate specific psychosis R31 was exhibiting.
Telemedicine Psychiatric Periodic Evaluation dated 620/4/23 indicates, (R31) has had psychotic and
aggression symptoms with staff associated with cares and ADL's (Activities of Daily Living) but none noted
since 6/11/23.
Evaluation does not indicate specific psychosis R31 was exhibiting.
Care Plan dated 8/3/22 indicates, Olanzapine related to Unspecified Psychosis not due to a substance or
known physiological condition. Care Plan indicates R31 is noncompliant with care/showers;
verbally/physically aggressive; has a behavioral problem - strikes out at caregivers related to dementia. The
Care Plan does not include any psychotic behaviors with main behaviors exhibited as aggressive to staff
with cares.
2) Current Physician order Report Summary indicates R33 has orders for Seroquel (antipsychotic) 25mg
twice daily ordered on 4/5/23 for Depression/Delusions.
Physician Summary Report indicates R33 is [AGE] years old and has diagnoses that includes Alzheimer's
Late Onset (1/4/21) and Delusional Disorder (12/31/20).
Consent For Psychotropic Medication 2/17/21 indicates consent was given on that date for R33 to receive
Seroquel (antipsychotic) 50mg daily. No indication for use, diagnosis or target behaviors were
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145619
If continuation sheet
Page 2 of 3
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
07/14/2023
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)
F 0758
documented on the consent for Seroquel.
Level of Harm - Minimal harm
or potential for actual harm
Behavior Monitoring and Intervention Report for June/July 2023 indicates on 6/6/23, R33 entered other
resident's rooms/personal space, was hoarding, pacing and wandering. Report indicates R33 did not
display any other behavior(s) in 60 days.
Residents Affected - Few
On 7/13/23 at 9:45am V10, CNA stated R33 doesn't display any behaviors anymore. V10 stated R33
previously would run in the hallway and try to go out the exit door.
Current Care Plan dated 8/17/22 indicates R33 receives Seroquel for depression and delusions; wanders
and is an elopement risk related to dementia. Care plan also indicates R33 has a behavior problem of
striking out at caregivers related to dementia.
No target behaviors or identification of delusions is documented in R33's care plan.
Both R31 and R33 were observed during various times of the day - both in bed and in the milieu - on
7/11/23, 7/12/23 and 7/13/23 and both were calm with no observable behaviors.
On 7/12/23 at 1:45pm V3, Nurse Consultant stated they are working on better behavior monitoring, more
specific behaviors, and a new psychotropic consent form.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145619
If continuation sheet
Page 3 of 3
