Health inspection·November 22, 2024

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a diagnosed mental disorder for 1 (R27) of 1 resident reviewed for PASRR Screening in the sample of 18. Residents Affected - Few Findings Include: 1. R27's admission Record documented an initial admission date to the facility of 1/23/23. The current admission Date is listed as 05/10/2024 and included a diagnosis of psychotic disorder with delusions due to known physiological condition with onset date of 05/10/2024. R27's Notice of PASRR Level I Screen Outcome dated 5/7/24 documented a PASRR Level I Determination of No Level II Required - No SMI (Serious Mental Illness)/ID (Intellectual Disability/RC (Related Condition). In the section titled Diagnoses under Mental Health Diagnoses this document noted No mental health diagnosis is known or suspected. Under the section titled Mental Health Medications it is noted that R27 was currently prescribed: Zyprexa pill, 2.5mg/day for a diagnosis of Altered Mental Status. Under the section titled Ascend Outcome it's documented No Level II Required - No SMI/ID/RC. Rationale: The Level I screen indicates that a PASRR disability is not present because of the following reason: There is no evidence of a PASRR condition of an Intellectual/developmental disability or serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. R27's Minimum Data Set, dated [DATE] in Section I - Active Diagnoses documented a diagnosis of psychotic disorder (other than schizophrenia). On 11/22/24 at 9:01 AM, V7 (Business Office Manager) stated she was responsible for ensuring residents' PASRR screenings were completed. V7 said R27's admission was prior to V7 being hired, and V7 was not sure why a PASRR Level II screening was not completed for R27. V7 said she would make a referral to have R27's PASRR Level II screening completed. On 11/22/24 at 10:44 AM, V1 (Administrator) acknowledged the error in the PASRR screening of R27 and stated R27 will be referred to have the Level II completed. V1 said she expected staff would follow the facility's PASRR policy. V1 said the facility would conduct an audit to ensure no other residents were also eligible to have a Level II screening. The facility's 11/13/18 Preadmission Screening and Annual Resident Review (PASARR) policy documented in part . Procedure . 1. admission and readmission . a. The facility will participate in or complete the Level I screen for all potential admissions regardless of payer source to determine if the Page 1 of 6 145759 145759 11/22/2024 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0645 Level of Harm - Minimal harm or potential for actual harm individual meets the criterion for mental disorder . intellectual disability . or related condition . b. Based upon the Level I screen, if an individual is determined to meet the above criterion, the facility will refer the potential admission to the State PASARR representative for the Level II screening process . Residents Affected - Few 145759 Page 2 of 6 145759 11/22/2024 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on observation, interview and record review, the facility failed to maintain a full time Director of Nursing and to have a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 34 residents living in the facility. Findings Include: The Long Term Care Facility Application For Medicare and Medicaid document dated 11/19/2024, documents 34 residents residing in the facility. The facility's nursing schedules document there was no RN on shift for coverage on the following dates: 9/3/2024, 9/7/2024, 9/21/2024, 9/25/2024, 9/26/2024, 9/30/2024, 10/5/2024, 10/9/2024, 10/10/2024, 10/14/2024, 10/15/2024, 10/19/2024, 10/21/2024, 10/22/2024, 10/23/2024, 10/28/2024, 10/29/2024, 11/6/2024, 11/13/2024,11/14/2024, 11/18/2024, 11/19/2024 and 11/21/2024. On 11/21/2024 at 10:45 AM, V1 (Administrator) and V3 (Regional Manager) both stated that the facility currently did not have the services of a Director of Nurses (DON) or a Registered Nurse (RN) eight hours a day, seven days a week. V2 and V3 stated the facility was actively in the process of trying to hire a full time RN. At this time, V1 stated that they had been without a DON since 4/29/2024. V1 further stated that they are really trying to recruit an RN to work here so they can accept more residents, but with the lack of coverage they are limited on what they can accept. On 11/20/2024 at 12:30 PM, V2 (Assistant Director of Nursing/Licensed Practical Nurse) stated that there has not been a DON since she started working here in June of 2024. On 11/21/2024 at 2:00PM, V4 (Licensed Practical Nurse) stated that there are many days when no RN is on shift. V4 stated that currently they do not have any residents requiring treatments that only RN's can do, like IV (Intravenous) antibiotics. The Personnel Policy, dated September 2024, documents: To define basic staffing requirements and patterns for all facility personnel 1. The facility operates in compliance with applicable federal, state, and local laws, regulations and codes with accepted professional standards and principles that apply to professionals. Standards for individual positions may be found with the appropriate department staffing patterns in the departmental manuals 145759 Page 3 of 6 145759 11/22/2024 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

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 interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 2 (R5, R24) of 5 residents reviewed for Gradual Dose Reductions (GDR) in a sample of 18. Findings Included: 1. R5's admission Record documented an admission date of 7/21/2012 and included diagnoses of unspecified dementia, unspecified severity, with psychotic disturbance, depression unspecified and anxiety. R5's current Medication Administration Record (MAR) for November 2024 documented R5 is prescribed the following psychotropic medications: Duloxetine 30mg (milligrams) take one capsule by mouth once daily at 8 AM, Alprazolam (sub for Xanax) .25mg tablet take ½ tablet (.125) by mouth twice daily at 8 AM and 5 PM, Risperidone .25mg tablet take 1 tablet by mouth twice daily at 8 AM and 5 PM, Trazodone 50mg tablet take ½ tablet (25mg) by mouth daily at 5 PM, and Zoloft (Sertraline) 25mg 1 tablet by mouth daily at 5 PM. A Pharmacy Consultation Report dated 4/29/2024 documented the following: Under Comment: R5 has received an antidepressant, sertraline 25 mg daily for management of depressive symptoms since 11/2023. Under Recommendation: documents, If this therapy is to continue at the current dosage, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences (e.g., appetite changes, falls), and check DECLINE below .Alternatively, please attempt a gradual dose reduction (GDR) of sertraline to 25mg QOD (every other day) X (times) 2 weeks, then discontinue. Under Rationale for recommendation: documents Dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence (e.g., GDR is attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a psychotropic medication or after the prescriber has initiated such medication, unless clinically contraindicated. This consultation report with pharmacist recommendations was signed by the Consultant Pharmacist on 4/29/24. Under the Physician's Response, V6 (Physician) checked the section that documented I decline the recommendation above because GDR is CLINICALLY CONRAINDICATED for this individual as indicated below. (NOTE: Please check option #1 or #2 AND provide patient specific rationale on the lines below). #1 is checked on this report, which documents Continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair the individual's function or cause psychiatric instability by exacerbating an underlying medical condition of psychiatric disorder AS DOCUMENTED BELOW. Under the section that states Please provide CMS (Centers for Medicare and Medicaid Services) REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual, V6 left this section blank, with no patient specific rationale provided to explain why the recommendation for reduction was being declined. Additionally, V6 did not signed this 4/29/24 recommended consultation report until 7/11/24. 145759 Page 4 of 6 145759 11/22/2024 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/21/2024 at 10:59 AM, V2 (Assistant Director of Nursing/Licensed Practical Nurse) stated she had not been employed with the facility at the time of the 4/29/24 pharmacy consultation report for R5, and she was not aware of why the GDR form had not been followed up on prior to 7/11/2024 by V6 (Physician). 2. R24's admission Record documented an admission date of 4/1/2022 and included diagnoses of unspecified dementia, unspecified severity, with other behavior disturbance, and depression. R24's current MAR for November 2024 documented R5 is prescribed Risperidone .25mg tablet, take one tablet twice daily (DX (diagnosis): Dementia w/ (with) behavioral disturbance). The most recent pharmacy Consultation Report provided by the facility was dated 8/07/2023 and documented the following: Under Comment: R24 receives Risperidone 0.25mg BID (twice per day) for expressions or indications of distress related to dementia (e.g., BPSD (behavioral and psychological symptoms of dementia), dementia with psychosis). Under Recommendation: documented Please attempt a gradual dose reduction (GDR) of Risperidone to 0.25mg HS (night) while concurrently monitoring for reemergence of symptoms and/or withdrawal symptoms. Under Rational for Recommendation documented CMS requires that antipsychotics, being used to treat expressions or indications of distress related to dementia be evaluated at least quarterly with documentation regarding continued clinical appropriateness. Dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence (e.g., GDR is attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a psychotropic medication or after the prescriber has initiated such medication, unless clinically contraindicated). Under Physician Response V6 (Physician) checked the box I accept the recommendation(s) above, please implement as written and signed the form on 8/9/23. There was no Pharmacy Consultation Report available or provided by the facility for August of 2024, when the next GDR would have been due. During the survey (11/19/24 - 11/22/24) however, the facility provided a Pharmacy Consultation Report dated 11/19/24, with a fax stamp showing the form was faxed to the provider/physician (V6) on 11/20/24. This Consultation Report documented the following recommendations from the pharmacist: Under Comment R24 receives Risperidone 0.25mg BID for expressions or indications of distress related to dementia with psychosis) since 8/17/23. According to the charting during this time period, she tolerated the medication reduction well. There are a couple notes of increased confusion, however she does have dementia and BIMS score was 4 on 9/20/23. She is also taking Mirtazapine 7.5mg HS for depression since 4/1/22. Under Recommendation documents Please attempt a gradual dose reduction (GDR) of Risperidone to 0.25mg daily. Under Rational for Recommendation: CMS requires that antipsychotics, being used to treat expressions or indications of distress related to dementia, be evaluated at least quarterly with documentation regarding continued clinical appropriateness. Dose reductions should occur in modest increments over adequate periods of time to minimize withdrawal symptoms and to monitor symptom recurrence (e.g., GDR is attempted in 2 separate quarters, with at least 1 month between attempts, within the first year in which an individual is admitted on a psychotropic medication or after the prescriber has initiated such medication, unless clinically contraindicated). This document was signed by the consultant pharmacist on 11/19/24, however the section for the physician to sign had not yet been completed. 145759 Page 5 of 6 145759 11/22/2024 Axiom Healthcare of Rosiclare 1807 Fairview Rd Rosiclare, IL 62982

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/20/24 at 1:30 PM, V2 stated she received the GDR form for Risperidone 0.25mg on 11/19/2024 and faxed it to V6 (Physician) for review, acceptance, or declining recommendation. V2 stated, she does not know why she received this GDR form in November 2024 and not within the year time frame of August 2023 to August 2024. On 11/21/24 at 9:52 AM, V3 (Regional Consultant) stated the facility does not have a specific GDR policy. V3 stated, the facility follows the regulations for GDR of psychotropic medications. On 11/21/24 at 10:11 AM, V1 (Administrator) stated her expectations for GDR psychotropic medications would be to follow the facility policy and/or the regulation guidelines that document to attempt reductions within the specified timeframes. V1 stated, the previous owners of the facility did not have a GDR policy and she was unaware if the new owners have a policy. V1 stated, she understands that if a medication review is not completed within the timeframe guidelines, then the resident would not be free from unnecessary medication. 145759 Page 6 of 6