Inspection·July 20, 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, record review and interview, the facility failed to attempt a Gradual Dose Reduction of a psychotropic medication for one of five residents (R15) reviewed for psychotropic medication use, in a sample of 37. Findings include: The facility policy, titled Psychotropic Medication Use and Behavior Monitoring (revised 2/11/22) documents, Psychotropic medications refer to drugs which are used for antipsychotic, antidepressant, antimanic, Sedative-hypnotic, and/or antianxiety purposes. It is the policy of this facility to keep each resident's medication regimen free from unnecessary drugs. Psychotropic medications will not be administered for purposes of discipline or staff convenience and when not required to treat the resident's symptoms. The policy later documents, The pharmacist consultant will complete monthly medication reviews reporting to the physician: Drugs prescribed without a supporting diagnosis; Dosage in excess of maximum strength as recommended by guidelines for geriatric residents; Multiple use of psychotropic drugs; No periodic evaluation of the residents need for the psychotropic drugs. The DON (Director of Nursing) will complete the Psychotropic Medication Reduction Request form and send to the physician indicating any behaviors the resident has exhibited since the last dose reduction to assist the physician in determining dose reductions of psychotropic medications. The Electronic Medical Record documents R15 was transferred to the facility on 9/03/19 from the Hospital with the diagnosis of Vascular Dementia with Delusions and discharge orders to administer Zyprexa (Antipsychotic) 5 mg (milligrams) at bedtime. R15's Pharmacy Consult, dated 3/02/22 documents R15 had a failed Zyprexa reduction attempt in September 2021 and returned to the daily dose of 5 mg. R15's current Physician's Orders document R15 has continued to receive Zyprexa 5 mg at bedtime for the diagnosis of Vascular Dementia with Behavioral Disturbances, since 11/15/21, with no attempted reduction. R15 is also currently prescribed Lorazepam (antianxiety) 0.5 mg twice per day for Anxiety Disorder and Sertraline (antidepressant) 100 mg daily for Major Depressive Disorder. The Consultant Pharmacist documented he recommended a decrease in R15's Zyprexa 5 mg daily on 3/02/22 and 9/06/22, which were both declined by the physician. The most recent Consultant Pharmacist recommendation to reduce R15's Zyprexa, dated 3/03/23, documents the physician again declined a decrease due to Behavioral interventions continue to be attempted, except in emergency situation, and are included in the plan of care. The continued use is in accordance with relevant current standards of practice. A dose reduction at this time would likely impair resident's function or cause psychiatric instability by exacerbating an underlying psychiatric disorder while continuing to pose a danger to the resident or others as supported by the following Clinical Rationale and Evidence of the following symptoms: Delusions. A Progress Note, dated 4/11/23, documents, (V8/Physician) disagreed to pharmacist (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: 145933 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 145933 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apostolic Christian Skylines 7023 North East Skyline Drive Peoria, IL 61614 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)