Health inspection·January 2, 2025

F 0758 Level of Harm - 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 interview and record review, the facility failed to monitor for behaviors and report the side effects of a resident's anti-psychotic medication. This failure resulted in R4 continuing to receive Seroquel and experiencing a hospitalization, increased falls, and inability to participate in his rehab care. This applies to 1 out of 3 (R4) residents reviewed for psychotropics. The findings include: R4's EMR (Electronic Medical Record) showed R4 was admitted to the facility on [DATE] with multiple diagnoses including a history of falls, metabolic encephalopathy, vascular dementia, depression, epilepsy, convulsions, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, urinary tract infections, and left femur fracture. R4's MDS (Minimum Data Set) dated 10/18/2024 showed he was severely cognitively impaired and receiving high-risk medications including antipsychotics, antidepressants, and anticonvulsants. R4's EMR showed he was transferred to the hospital on [DATE] and did not return to the facility. On 12/31/2024 at 8:50 AM, V8 (R4's Wife) said she would visit R4 frequently at the facility and became worried because he started to become overly sedated as if drugged and having multiple falls. On 1/2/2025 at 9:00 AM, V14 (Registered Nurse/RN) said she had been R4's routine morning nurse during his stay at the facility. V14 said R4 was nice but would become agitated when his wife was not present. V14 said R4 was a high risk for falls and had to be redirected frequently. V14 said R4 was hospitalized because he was noted to be too sleepy. V14 said R4 was non-decisional and V8 (R4's Wife) was his representative and decision-maker. On 1/2/2025 at 10:20 AM, V12 (Geriatric Nurse Practitioner/NP) said she had assisted in managing R4's primary care at the facility. V12 said she did not prescribe R4's Seroquel medication but had decreased, held, and discontinued it because she was informed he was too sedated. V12 said R4's behavior was difficult to manage and difficult to find the right balance of treatment. V12 said ultimately V13 (R4's Psychiatric NP) should have been notified as the ordering prescriber for Seroquel. On 1/2/2025 at 11:00 AM, V13 (Psychiatric NP) said she was consulted to treat R4 for behavior of agitation related to his dementia and managing his Seroquel. V13 said she last saw R4 on 11/7/2024 and decreased his Seroquel after she was informed of his fall. V13 said the facility should have called her first to inform her of R4's side effects as practice for managing residents receiving Page 1 of 4 145689 145689 01/02/2025 Pearl of Elk Grove, The 1920 Nerge Road Elk Grove Village, IL 60007

F 0758 Level of Harm - Actual harm Residents Affected - Few psychotropics. V13 said R4 had a lot of adjustments in a short period of time, which made it harder to identify the right dose for him. V13 said this could have contributed to R4 becoming more unstable and lethargic. V13 said it was always better to be cautious when using antipsychotics and that's why she started to taper his Seroquel in November. V13 said she did not contact R4's wife but discussed her recommendations with the facility's nurses. V13 said R4 was showing signs of sundowning (increased confusion in the evening hours) and would have also benefited from nonpharmacological approaches such as sleep hygiene promotion practices, activities, and family visits in the evenings. R4's comprehensive care plan showed R4 had a focus problem for the use of Seroquel (antipsychotic) medication for Alzheimer's disease initiated and last updated on 6/6/2024. The focus problem included a goal for R4 to reduce the use of psychotropic medications and included the interventions of Monitor for side effects and effectiveness [every] SHIFT. Consult with pharmacy, MD to consider dosage reduction when clinically appropriate at least quarterly. R4's care plan did not show any resident-centered target behaviors or non-pharmacological approaches for the use of Seroquel. R4's Order Summary Report dated 1/2/2025 showed R4 was started on SEROquel Oral Tablet 25 MG [milligrams] Give 1 tablet by mouth two times a day for depression on 6/6/2024. R4's EMAR (Electronic Medication Administration Record) showed R4 received Seroquel 25 mg twice a day until 9/10/2024. The Report showed R4 was started on an additional dose of SEROquel Oral Tablet 25 MG Give 1 tablet by mouth at bedtime related to UNSPECIFIED DEMENTIA on 6/13/2024. R4's EMAR showed R4 received Seroquel 25 mg at bedtime as well until 8/14/2024. R4's Order Summary Report showed R4 was started on an additional as needed dose of SEROquel Oral Tablet 25 MG by mouth every 24 hours as needed for Behavioral disturbances on 7/29/2024. R4's EMAR showed R4 had the order active for Seroquel PRN (as needed) until 10/15/2024 (79 days). The EMAR showed R4 received Seroquel PRN on 8/1/2024, 8/14/2024, and 8/23/2024. R4's Order Summary Report then showed R4's Seroquel at bedtime was increased to 75 mg on 8/15/2024 with the order SEROquel Oral Tablet 25 MG give 3 tablet by mouth at bedtime related to UNSPECIFIED DEMENTIA. R4's Progress Note dated 9/11/2024 said, Informed [V12 (Geriatric Nurse Practitioner/NP)] patient is sleeping most of the time in the morning after breakfast fall asleep again .D/C Seroquel during the day and leave Seroquel at bedtime, hold if sedated. V13's Psychiatric Periodic Evaluation note dated 9/12/2024 said, Nursing staff reported that dosage of Seroquel during the day was discontinued due to excessive daytime sedation. The evaluation said R4 was to continue with Seroquel 25 mg every 24hrs PRN, Seroquel 75 mg at bedtime for agitation/Psychosis, and to monitor for changes in mood and behaviors. R4's Pharmacy Recommendation dated 9/16/2024 said there were recommendations for a GDR (gradual dose reduction) for SEROQUEL 75MG QHS and a need for stop date of 14 days for PRN order for Seroquel. The recommendation was declined by V13 (Psychiatric NP) because the Patient has had good response to treatment and requires this dose for condition stability. R4's EMAR showed R4 received Seroquel 75 mg at bedtime until 9/17/2024. R4's Progress Note dated 9/18/2024 said, Informed [V12 (Geriatric NP)] that patient during the day there are times that patient is just sleeping, doesn't want to participate in the therapy .order reduce seroquel 50mg at bedtime. 145689 Page 2 of 4 145689 01/02/2025 Pearl of Elk Grove, The 1920 Nerge Road Elk Grove Village, IL 60007

F 0758 Level of Harm - Actual harm Residents Affected - Few V13's Psychiatric Periodic Evaluation note dated 9/19/2024 said, The patient was referred to us today due to worsening depression and a lack of motivation. According to nursing staff, the patient has displayed little motivation lately, dragging himself around and showing a disinterest in participating in any activities, indicating worsening depression. The patient was seen sitting around the nursing station, confused at baseline, and was unresponsive during our interaction. Nursing staff recently discontinued his daytime dose of Seroquel, and while the patient is now more alert, he suntil does not engage much which is unusual for him. The evaluation said R4 was started on another psychotropic medication of Bupropion 100mg daily (antidepressant). R4's NP Progress Note from V12 (Geriatric NP) dated 9/20/2024 said, Pt seen for somnolence HPI Pt has been more sleepy. Seroquel reduced. V13's Psychiatric Periodic Evaluation note dated 10/3/2024 said Declined GDR recommendation for Seroquel at bedtime due to risk for decompensation. R4's Progress Note dated 10/14/2024 said, Resident slipped and fell from wheelchair hitting his head on the floor. Resident sustained a cut on his right forehead .Dr on file was reached and ordered resident to be sent out to ER. R4's Progress Note dated 10/15/2024 said, Pt is admitted for altered mental status. R4's Order Summary Report showed R4 was restarted on 50 mg at bedtime on 10/17/2024 with the order SEROquel Oral Tablet 25 MG Give 2 tablet by mouth at bedtime for bipolar disorder. The Report then showed on 10/26/2024, R4 was started on SEROquel Oral Tablet 25 MG Give 1 tablet by mouth two times a day for behavioral disturbances. R4's Progress Note dated 10/17/2024 said, Upon admission, res appeared very sleepy not verbally responsive even with much verbal cuing from staff and paramedics. His eyelids were quivering and throat had visible swallowing reflex. After about 10 minutes with verbal prodding from staff to say something res said hello and opened his eyes. R4's Progress Note dated 10/26/2024 said, Called [V13 (Psychiatric NP)] for patient being restless and keep on standing. Patient is very unsteady to stand up. NP ordered for Seroquel 25mg bid. Informed wife. R4's Progress Note dated 10/27/2024 said, Change in Condition/s reported this CIC Evaluation are/were: Altered mental status .Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Functional Status Evaluation: General weakness .Primary Care Provider responded with the following feedback .Monitor him closely. R4's Progress Note dated 11/2/2024 said SEROquel Oral Tablet 25 MG Give 1 tablet by mouth two times a day for behavioral disturbances patient appears calm and relaxed poa stated not to give. R4's Progress Note dated 11/7/2024 said, Seen by [V13 (Psychiatric NP)] due to sleepy during the day. D/C seroquel on 9am dose. R4's EMAR showed R4 received Seroquel 25 mg twice a day until 11/7/2024, and received Seroquel 50 mg at bedtime until 11/9/2024. R4's Progress Note dated 11/10/2024 said R4 fell and was transferred to the hospital for an evaluation. R4's EMARs from August through November 2024 showed an order for monitoring the use of Anti-Psychotic Medication Use: Observe closely for significant side effects, sedation, drowsiness, dry mouth, constipation, blurred vision, extra pyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Enter the number of times side effect noted. (Requires 145689 Page 3 of 4 145689 01/02/2025 Pearl of Elk Grove, The 1920 Nerge Road Elk Grove Village, IL 60007

F 0758 progress note of physician notification for each occurrence) every shift for Monitoring. R4's EMARs showed no side effects were documented for R4. Level of Harm - Actual harm Residents Affected - Few R4's EMARs from August through November 2024 showed an order for Monitor/Record if targeted behavior of Agitation occurs every shift for Monitoring indicate if behavior occurred by indication the number of times observed. R4's EMARs showed R4 had the behavior documented on 11/8/2024 and 11/9/2024. R4's Incidents By Incident Type fall report dated 1/2/2025 said R4 had a total of 20 fall incidents during his stay at the facility. The report showed R4's initial fall was on 6/9/2024 (after starting Seroquel). The report showed R4 also fell on 6/11/2024, 6/14/2024, 6/28/2024, 7/2/2024, 7/6/2024, 7/23/2024, 8/2/2024, 8/19/2024, 8/26/2024, 8/31/2024, 10/5/2024, 10/7/2024, 10/10/2024, 10/11/2024, 10/14/2024, 10/27/2024, 11/2/2024, 11/5/2024, 11/8/2024, and 11/10/2024. V16's (R4's Neurologist) Progress Notes dated 8/29/2024, 9/24/2023, and 10/31/2024 said [reccommend] limit seroquel. The facility's policy titled Psychotropic Drug Use dated 6/11/2024 said, The purpose is to promote the safe and effective use of psychotropic medications that are used in lowest possible dose and time frame and have indication for the use that enhances the resident's quality of life .Initiating the Use of Psychotropic Medications .4. Every attempt will be made to utilize the lowest possible dose of the medication .7. If an order is obtained for a Psychotropic Medication, the resident, family or POA must be informed of the risks and benefits of the medication The care plan will be developed with input from the resident, family, legal representative and include participation from the IDT (Interdisciplinary Team). 3. The care plan will be developed initially upon the start of the medication and be reviewed at least quarterly or more often as the resident's condition dictates .Monitoring and Gradual Dose Reduction .The Psychiatrist/PCP will review the continued need for the medication and monitor for side effects .The Psychiatrist or ANP will also be notified and review changes in the resident's condition and behavior or any side of the medications. The facility's policy titled Behavior and Psychoactive Management Program dated 10/22/2024 said, It is the policy of the facility to provide care and services to promote our resident's quality of life. It is the philosophy of the facility that all resident behavior has meaning. Our facility will work diligently to minimize the use of psychoactive medications in its resident population .a. Program will ensure that staff are monitoring residents' behavior to establish patterns, determine intensity and frequency behavior is exhibited, and identify specific targeted behavior/s that can be distressing to the resident. b. The program will assess the need for psychoactive medication use. Care plans with residents and or resident's representatives will be scheduled as necessary via phone or in person to discuss behaviors, psychoactive drug order/s and treatment, and recommended plan of care .e. Evaluating the effectiveness of pharmacological and non-pharmacological interventions will be performed. f. Monitoring for any adverse side effects of medications .g. Care plan on focus problem will be developed with approaches to address and manage identified behaviors .Tapering and Gradual Dose Reduction a. Facility will attempt to achieve the lowest effective dose, to discontinue the medications that no longer benefit the resident, and to minimize exposer to increased risk of adverse consequences .iii. Daily behavior monitoring. iv. May schedule resident and family meetings as necessary. 145689 Page 4 of 4