Inspection·September 21, 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. Based on observation, interview, and record review the facility failed to document and care plan targeted behaviors to warrant the use of an anti-psychotic medication, monitor for underlying conditions prior to increasing an anti-psychotic medication dose, and perform a comprehensive evaluation for the use of an anti-psychotic for one of one resident (R66) reviewed for anti-psychotic medication use with the diagnosis of Dementia in the sample of 31. Findings include: The facility's Psychotropic Medication Use and Behavior Monitoring policy dated 10/2021 documents, Psychotropic medication refers to drugs which are used for anti-psychotic, anti-depressant, anti-anxiety, and/or hypnotic purposes. It is the policy of the facility to keep each resident's medication regimen free from unnecessary drugs. Psychotropic medications will not be administered for the purpose of discipline or staff convenience and when not required to treat the resident's symptoms. Psychotropic drug therapy will be instituted at the lowest dose for the shortest duration of time to control the specific and documented behavioral problems as prescribed the physician. The resident's need for psychotropic medication will be monitored, as well as when the resident has received optimal benefits from the medication and when the medication dose can be lowered or discontinued. This monitoring shall include identification of the resident's behaviors that the psychotropic drug could conceivable address (target behaviors). Assessment of potential cause of the behaviors that, if addressed, could eliminate the behaviors without the use of psychotropic drugs (medical, environmental, family stresses, adjustment reactions, etc.) Discussion of non-medical behavior management strategies that have been implemented in an attempt to reduce/eliminate the behaviors prior to initiation of drug treatment and the resident's response to these interventions. Behaviors for which psychotropic medications should not be used include crying out, yelling, screaming, fidgeting, insomnia, nervousness, not-cooperative, poor self-care, restlessness, simple pacing, unsociability, and wandering. R66's Physician's Orders dated 2-15-23 document R66's Risperidone (anti-psychotic medication) was increased from 0.25 mg (milligrams) daily at bedtime to 0.5 mg daily at bedtime for the diagnosis of Behavioral Disorders associated with Dementia. R66's Physician's Orders dated 2-15-23 through 9-19-23 document R66 has received Risperidone 0.5 mg one tablet at bedtime for the diagnosis of Behavioral Disorders associated with Dementia since 2-15-23. R66's Electronic Health Record does not include documentation of the facility assessing or monitoring R66 for underlying conditions prior to increasing R66's Risperidone on 2-15-23. (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: 145673 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 145673 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Home of Eureka 610 Cruger Eureka, IL 61530 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)