Health inspection·May 18, 2023

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management for one of three residents (R34) reviewed for pain management in the sample of 27. This failure resulted in R34 experiencing severe pain and Physical Therapy shortening therapy with R34 on 5/15/23. Residents Affected - Few Findings include: The Facility Policy: Management of Pain dated 4/4/12, documents Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. A standard format for assessing, monitoring, and documenting pain in both cognitively intact and cognitively impaired residents will be utilized. As part of a comprehensive approach to pain assessment and management, pain will be considered the fifth vital sign at the facility, along with temperature, pulse, respiration, and blood pressure. For the purpose of this policy, pain is defined as whatever the experiencing person says it is, existing whenever the experiencing person says it does. On 05/15/23 11:30 AM, R34 was sitting in her wheelchair with a frown on her face. (R34) stated (R34) was having severe pain in (R34's) side and is supposed to be getting Norco (Hydrocodone-Acetaminophen oral tab 5-325 milligrams/mg), but the facility does not have Norco. R34 also stated I know they have it (Norco) in a convenience box (C-Box), but they need authority to get in the box. I am hoping they will get it today but none so far. I have therapy every day, but I couldn't do it today because I hurt too bad. I was told it may be 8:00 PM before they get the medication. I took Tylenol earlier this morning, but it doesn't work as well as the Norco. On 5/15/23 at 11:35 AM, V3 (Licensed Practical Nurse) stated that V34's Norco was increased due to V34 having chronic pain. V34 ran out of the Norco last night (5/14/23). We asked V6 (R34's Primary Physician) to send an order to the pharmacy. Once the pharmacy gets the order, they will call us, and we can get the medication out of the Convenience Box. On 5/17/213 at 10:15 AM, V2 (Director of Nursing) stated that on 5/12/23 at 5:45 PM, R34's Norco order was changed from one tab to two tabs. The last Norco the facility had available for R34 was given to R34 on 5/15/23 at 12:15 AM. The facility policy is that the pharmacy must verify the order before we can pull it from the convenience box. There was Norco in the convenience box, but the facility was not allowed to take it from the C-Box without permission. The next time R34 got Norco was on 5/15/23 at 1:37 PM. V2 also stated We should have contacted (V6/R34's Primary Physician) sooner to get the medication here so (R34) would not have had pain. Page 1 of 5 145952 145952 05/18/2023 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0697 Level of Harm - Actual harm On 5/17/23 at 11:35 AM, V4 (Therapy Manager) stated that R34 is getting therapy every day. On Monday 5/15/23, around 8:30 AM, R34 stated that she was in a lot of pain and did not know if she could do therapy. V5 (Physical Therapy) worked with R34 for a while on 5/15/23 but cut the session short because the resident was having pain. V5 told V3 that R34 was having pain. Residents Affected - Few On 5/17/23 at 11:40 AM, V5 (Physical Therapy) stated that around 9:00 AM, on 5/15/23 R34 told V5 that she was having pain. V5 told V3 (Licensed Practical Nurse) that R34 was having pain and wanted pain medication. V3 told V5 that he had to get a script from V6 (R34's Primary Care Physician) for Norco for the pharmacy to allow him to remove the medication from the C- Box. R34 usually does 30 to 45 minutes of therapy but only did 25 minutes because of her pain. Around 11:00 AM, V5 went back to talk to V3 again to see if R34's pain medication was available. V3 stated that it could be as late as 8:00 PM, to get the Norco. On 5/18/23 at 10:45 AM, V1 (Administrator) stated that it takes a long time to get medication from the pharmacy or authorization to get in the C-Box if a resident runs out. When staff saw the medication was getting low the medication should have been ordered at that time instead of waiting until the last dose was given. R34's current Medical Record, documents R1 was admitted to the facility on [DATE] with diagnoses which included Aftercare following Joint Replacement, Presence of Right Artificial Hip Joint, Chronic Pain, Unilateral Primary Osteoarthritis (Right Hip), and Fibromyalgia. R34's Order Summary Report dated 5/17/23 at 9:50 AM, documents Hydrocodone-Acetaminophen Tablet 5-325 mg, give two tablets by mouth every six hours as needed for pain. 5/12/23 is the start date for the order. R34's Care Plan dated 4/24/23, documents R34 has chronic right hip pain, left knee pain and Diabetic neuropathy. Interventions: Administer analgesia as ordered. Give 30 minutes before treatment or care. Anticipate R34's need for pain relief and respond immediately to any complaint of pain. R34's Medication Administration Record dated 5/1/23 - 5/31/23 documents an order for Tylenol 325 mg, take 2 tablets by mouth every 4 hours as needed for pain. The Tylenol was given on 5/15/23 at 4:58 AM, and 12:15 PM with each pain level being a 10. An order for Hydrocodone-Acetaminophen Tablet 5-325 mg, give two tablets by mouth every six hours as needed for pain related to Fracture of Unspecified Part of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing. The Norco was given on 5/15/23 at 12:15 AM (pain level 10), then not given again until 1:37 PM on 5/15/23 (pain level 9). R34's Physical Therapy Progress Report dated 5/17/23 at 12:03 PM, documents that on 5/15/23, R34 was complaining of pain in her lower back during therapy treatment. Therapy was cut short, and nursing was notified. 145952 Page 2 of 5 145952 05/18/2023 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

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 observation, interview, and record review the facility failed to document appropriate indications for use of an antipsychotic medications and initiate gradual dose reductions at least yearly for three of five residents (R27, R41, R61) reviewed for unnecessary medications in the sample of 27. Findings include: The Facility's Psychotropic Medication Policy revised 11/28/17, documents, Additionally, Antipsychotic medication may be indicated for use if: 1) Behavioral Symptoms present a danger to the resident or others; 2)Expressions or indications of distress that are significant distress to the residents: 3) If not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presented a danger or significant distress; and or 4)GDR (Gradual Drug Reduction was attempted, but clinical symptoms returned. 1. On 5/16/23 at 10:30 a.m., R27 was sitting in the family room with no behaviors observed. R27's MDS (Minimum Data Set) assessment dated [DATE] documents R27 is severely cognitively impaired, has no delusions/hallucination and no behaviors towards others. According to R27's current POS (Physician Order Sheets) R27 receives Quetiapine Fumarate (Seroquel)12.5 mg (milligrams) in the morning five days a week related to Psychotic Disorder with Delusions due to Known Physiological Condition. R27 also has Diagnosis of Dementia with agitation. R27's Psychopharmacological Medication Flow sheet documents R27 started Seroquel 12.5 mg 5 times weekly on 5-6-22. R27's Physical Device/Psychoactive Medication Initial and Quarterly Evaluation dated 5/10/23 documents there has been no Reduction Attempted for the Seroquel. This same report documents on 12/22/22 and on 2/2/23 R27's physician declined a reduction. R27's Mood/Behavior Tracking dated 2/22/23 through 5/11/23 documents R27's behavior tracking documents Behaviors as being tracked as: Hitting, pushing, kicking staff with cares, and humming/moaning loudly. R27's behavior plan of care initiated on 5/11/23 documents, I have a behavior problem related to disruptive sounds, screaming out at others, wandering, agitation, exit seeking and refusing cares. On 5/15/23 at 9:15 AM, V7 /RN (Registered Nurse) stated, (R27) is a sweet man, he gets irritated with staff but is not a harm/threat to himself or other residents. On 5/17/23 at 9:15 AM, V8 Restorative Nurse stated, R27 is not a threat/harm to himself or to others. 2. On 5/17/23 at 2:10 p.m., R41 was asleep in his room with no noted behaviors. 145952 Page 3 of 5 145952 05/18/2023 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0758 On 5/18/23 at 10:14 a.m., R41 was asleep in his recliner with no noted behaviors. Level of Harm - Minimal harm or potential for actual harm R41's current Physician Order Sheet documents R41 takes Risperdal 1 mg (milligram) by mouth at bedtime (started on 12/6/21) for a diagnosis of Hallucinations. Residents Affected - Few R41's Minimum Data Set assessment dated [DATE], documents R41 has severely impaired cognition, has no delusions/hallucinations and no behaviors towards others. , R41's Behavior Tracking dated 3/1/23 through 5/17/23, document R41 does not have any behaviors to justify the use of an antipsychotic medication. R41's medical record including the Care Plan dated 4/24/23, does not document R41's target behaviors for the use of an antipsychotic medication. R41's Psychoactive Medication Quarterly Evaluation dated 2/14/23, states 1. Which of the following behavioral factors are present? (the facility marked) 10. Resident has a diagnosis of Alzheimer's/Dementia. R41's Pharmacist Recommendations dated 5/3/22, documents R41's physician refused the GDR request on R41's Risperdal 1 mg due to R41 being high risk for relapse. (R41's Risperdal had not been reduced since admission) R41's Pharmacist Recommendations dated 11/1/22, documents R41's physician ordered R41's Risperdal be reduced to 0.5 mg every bedtime. R41's Psychoactive Medication Quarterly Evaluation dated 2/14/23, states Family refused (Risperdal) dose reduction from (R41's physician) on 11/30/22. On 5/18/23 at 9:30 a.m., V9 (Licensed Practical Nurse) stated R41's only behavior is trying to get up out of his wheelchair, but he has no aggressive type of behaviors and is not a threat to harm himself or others. On 5/18/23 at 9:35 a.m., V10 (Licensed Practical Nurse) stated R41's behaviors is trying to get up without assistance. V10 stated We have to keep him close by the nurse's station, in his recliner, or his bed. He is confused due to having Dementia, but he isn't mean or anything like that. He can get a little grouchy with staff but he's not aggressive. I'm not aware of him ever being a threat to himself or others. On 5/18/23 at 9:50 a.m., V11 (Certified Nurse Aide) stated (R41) doesn't really have behaviors. He's not a threat to hurt himself or others. He may get a little grouchy with (staff) but he's really a sweetheart. Not a problem at all to take care of. He sleeps a lot. 3. On 5/17/23 at 11:22 a.m., R61 was in his room watching television. R61 was pleasant and did not exhibit any type of behaviors. On 5/18/23 at 10:20 a.m., R61 was out of the facility with his family. R61's Physician Order Summary Report dated 5/17/23, documents R61 has diagnoses which include Dementia with Psychotic Features and receives Abilify (Antipsychotic) 5 mg every morning (started 145952 Page 4 of 5 145952 05/18/2023 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0758 1/5/23). Level of Harm - Minimal harm or potential for actual harm R61's Behavior Tracking dated 3/1/23 through 5/17/23, documents R61 did not exhibit behaviors to justify the use of an antipsychotic medication. Residents Affected - Few R61's medical record including the Care Plan dated 4/24/23, does not document R61's target behaviors for the use of an antipsychotic medication. R61's Minimum Data Set assessment dated [DATE], documents R61 has no behaviors. On 5/18/23 at 9:30 a.m., V9 (Licensed Practical Nurse) stated I'm not aware of (R61) having any behaviors. He's out of the facility with his family right now. On 5/18/23 at 9:35 a.m., V10 (Licensed Practical Nurse) stated I don't have any problems with (R61) having any behaviors. Sometimes he can be a little demanding but it's not an issue. He is not a threat to harm himself of others. He goes out of the facility with his family quite a bit and has visitors daily. On 5/18/23 at 9:50 a.m., V11 (Certified Nurse Aide) stated (R61) has days that he is confused but he doesn't have what I would call behaviors. Sometimes he will get upset because he realizes he's confused and it's hard on him. He's usually somewhat independent with cares depending on his confusion at the time. On 5/18/23 at 11:30 a.m., V12 (Care Plan Coordinator) states there are no documented behaviors in R41 or R61's medical records to justify the use of antipsychotic medications. V12 stated R41's Risperdal has not had a gradual dose reduction since first R41's admission on [DATE]. V12 stated R41's family refused the Risperdal reduction order by the physician on 11/30/22. V12 stated R41 and R61's care plan do not document their antipsychotic medications with targeted behaviors, or individualized interventions. 145952 Page 5 of 5