Inspection·February 20, 2025

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 interview and record review, the facility failed to follow their policy related to psychotropic medications and ensure one resident (R49) was free from unnecessary psychotropic medications. Findings Include: R49 is an [AGE] year-old female who admitted to the facility on [DATE] and continues to reside in the facility. R49 has multiple diagnoses including but not limited to the following: difficulty in walking, lack of coordination, and osteoarthritis. Per physician orders resident is receiving Quetiapine Fumarate Oral Tablet 25 mg - Give 0.5 tablet by mouth at bedtime for sleep/anxiety. On 2/19/2025 at 12:25PM, R49 was noted to be calm and alert and oriented with no behaviors. On 2/19/2025 at 1:30PM, V2 (Director of Nursing) said, R49 came to the facility already receiving an antipsychotic medication. The attending physician is to decide whether to refer them to receive psychiatric care. She was seen on 2/19/2025 and there was no recommendation for psychiatric evaluation. Per progress note, there was no concerns identified with R49's mental health. R49 does not have any serious mental illness diagnoses. On 2/20/2025 at 12:15PM, V19 (Nurse Practitioner) said, I am unsure as to why R49 is on this medication or when she started taking this. When I have seen R49, she doesn't display any issues or behaviors. I have not witnessed her display any sort of anxiety or sleeplessness out of the ordinary. Review of records for R49 does not have a diagnosis of a serious mental illness, insomnia, or anxiety. No behavior documentation or indication for use of medication was given to this surveyor. Facility policy titled Psychotropic Medication Use with Revision Date of December 2024 states in part but not limited to the following: Policy Interpretation and Implementation: 1. Residents will only receive psychotropic/antipsychotic medications when necessary to treat specific conditions which they are indicated and effective. 4. The attending physician and facility staff will identify acute psychiatric episodes and will differentiate them from enduring psychiatric conditions. (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: 145932 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 145932 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Citadel Care Center-Wilmette 432 Poplar Drive Wilmette, IL 60091 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)