Health inspection·March 4, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and interviews, the facility failed to provide person-centered care planning for a resident ' s behavioral concern who refused psychotropic medication for 1 (R1) of 3 residents reviewed for inadequate nursing care. This failure impacted 1 resident (R1) who expressed behavioral concerns and continues to refuse medications that may help with behavioral concerns. Without adequate care planning addressing medication refusal, resident (R1) has the potential to continue to express behavioral concerns. Findings include: R1 is [AGE] years old, initially admitted on [DATE] with medical diagnosis of mood affective disorder, anxiety disorder, cocaine abuse, bipolar disorder, manic severe disorder. Per MDS (Minimum Data Set) assessment, R1 cognition is intact with a BIMS (Brief Interview for Mental Status) of 15. On 02/27/2025 at 11:17 AM, during initial review, facility staff V4 (Registered Nurse) noted that R1 was out on pass. R3 roommate of R1 was present during this time. R3 said, I think he is a guy that always something ain't right. R3 was asked to elaborate what he means with his statement. R3 stated, Something always wrong with him. I mean he always complaining. At 12:01 PM, V3 (Case Manager of R1 / Emergency Contact of R1) stated that R1 was complaining about mistreatment, and not getting respect he deserves. V3 stated that R1 told him that R1 had a verbal altercation with a staff member. And that R1 has repeatedly spoken his unhappiness in the facility. R1 did not say that staff hit him. V3 said, No, staff not physical aggressive but verbally negligence. V3 made as an example that R1 was asking for Robitussin 4 or 5 times. And after that, staff told R1 that there is no more Robitussin. V3 stated that he was informed by R1 that he refused medication because he does not trust staff in the facility that gives his medication. V3 was asked in his determination, R1 is a victim of abuse. V3 replied, No, I haven't witness it. I could not say that staff are abusive, I only have what he was saying. All I can say is what I witness. I cannot say staff was abusive with him. I can only say what I witness. Review of R1's notes documents multiple behavioral concerns between R1 to staff or other residents. R1 went to the hospital on [DATE] due to aggressive behavior towards staff and peers. Per V7 (Social Worker) notes dated 01/24/2025, it documents that V3 (Case Manager of R1) was given an update about R1's aggression towards staff and peers. R1 returned in facility on 01/29/2025. Per R1's physician orders psychotropic medication were ordered related to R1's behavior. Hydroxyzine HCl 25 MG (antianxiety) to be given twice a day for anxiety and agitation order date 01/22/2025. And Seroquel 50 MG (antipsychotic) to be given every 12 hours for bipolar and manic severe disorder with order date of 01/29/2025. Page 1 of 2 145661 145661 03/04/2025 Ryze West 5130 West Jackson Boulevard Chicago, IL 60644

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R1's Medication Administration Record (MAR) for January and February 2025 documents that almost every day Hydroxyzine and Seroquel was not given due to refusal. On 02/28/2025 at 10:47 AM, V2 (Director of Nursing) stated that R1 was verbally aggressive to staff and other residents with frequent room changes. R1 was involuntary discharge on [DATE] because of his behavior. V2 stated that R1 aggression was more on verbal. V2 stated that R1 has psychotropic medication Hydroxyzine and Seroquel for his behavior. And that R1 did not take his psychotropic medication. Because R1 did not take his psychotropic medication, it did not help him. V2 stated that if only R1 takes his psychotropic medication it would help with his behavior. V2 said, That is how he (R1) became this behavior. Verbally vocal and disrespectful from the time he wakes up to the time he sleeps. V2 was requested to review full care plan of R1 to address identified problem of refusing psychotropic medication. V2 after reviewing full care plan of R1 and said, I do not see it, about his (R1) refusal of psychotropic medication. I understand it needs to be addressed in the care plan. Care plan policy dated 01/2023 reads: The facility must develop a comprehensive care plan person-centered care plan for each resident. This comprehensive care plan should drive the care and services provided for the resident and allows for the highest level of physical, mental, and psychosocial function based of comprehensive assessment. 145661 Page 2 of 2