Health inspection·July 14, 2023

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 Page 1 of 3 145619 145619 07/14/2023 Allure of Lake Storey 1250 West Carl Sandburg Drive Galesburg, IL 61401

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 145619 Page 2 of 3 145619 07/14/2023 Allure of Lake Storey 1250 West Carl Sandburg Drive Galesburg, IL 61401

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. 145619 Page 3 of 3