Health inspection·May 8, 2024

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R32's Psychopharmacological Medication Flow Sheet documents R32's Seroquel (anti-psychotic medication) was decreased on 12-12-23 from 12.5 mg (milligram) daily on Mondays, Wednesdays, and Fridays to 12.5 mg on Mondays and Fridays only for the diagnosis of Psychosis. R32's Psychopharmacological Medication Flow Sheet documents R32's Seroquel was increased to 12.5 mg daily on 1-10-24 for the diagnosis of Psychosis. R32's Order Summary Report dated 5-5-24 documents R32 has the diagnoses of Psychotic Disorder with Delusions and Alzheimer's Disease. This same Order Summary Report documents R32 has been receiving Seroquel at 12.5 mg daily since 1-10-24 for the diagnosis of Psychosis. R32's BIMS (Brief Interview of Mental Status) dated 4-11-24 documents R32 is severely cognitively intact and has no behaviors that put him at risk of harm to themselves or others. R32's Health Status Note dated 12-31-2023 documents at approximately 8:00 PM R32 was observed face down on the floor in the hallway with the wheelchair behind him. R32 had laceration to the bridge of his nose and nares with active bleeding. R32 stated he, wanted to get up. Prior to change in elevation R32 was in the hallway by nurses' office conversing with another peer with staff in hallway. R32 refused to go to bed at 7:45 PM when asked if he was ready for bed and he said not yet and pointed at another resident with whom he had been conversing with. R32 was combative with staff when staff attempted to push his wheelchair down the hallway towards his room at approximately 6:30 PM. R32's Progress Notes dated 12-31-23 at 10:29 PM documents R32 was being treated at the emergency room for a fractured nose. R32's Health Status Note dated 1-10-24 at 2:32 PM documents R32 received a new order to increase Seroquel to 12.5 mg daily related to increased restlessness and agitation. On 5-5-24 at from 9:15 AM through 11:43 AM R32 was sleeping in a low bed with fall mats on the floor beside both sides of the bed. On 5-07-24 at 01:42 PM V5 (CNA/Certified Nursing Assistant) stated, (R32's) behaviors that I am aware of is that he moans during cares. (R32) does not have any other behaviors. On 5-07-24 at 11:47 AM V3 (MDS Coordinator) stated, The only reason (R32) got his Seroquel increased to 12.5 mg daily on 1-10-24 was because he fell out of his wheelchair and face planted. (R32) got Page 1 of 13 145952 145952 05/08/2024 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0605 a laceration. Level of Harm - Minimal harm or potential for actual harm 3. R57's Physician's Orders and Psychopharmacological Medication Flow Sheet documents R57's Abilify (Anti-Psychotic Medication) 1 mg (milligram) given twice weekly on Wednesdays and Saturdays for the diagnosis of Dementia with Psychosis was discontinued on 11-28-23. Residents Affected - Few R57's Physician's Orders and Psychopharmacological Medication Flow Sheet dated 12-2-23 documents R57's Abilify 1 mg given twice weekly on Wednesdays and Saturdays for the diagnoses of Dementia with Psychosis was restarted. R57's Physician's Orders and Psychopharmacological Medication Flow Sheet dated 1-26-24 documents R57's Abilify was increased to 5 mg daily for the diagnosis of Dementia with Psychosis. R57's Order Summary Reports dated 1-26-24 through 5-6-24 documents R57's Abilify has remained the same dose of 5 mg daily for the diagnosis of Dementia with Psychosis. R57's BIMS dated 3-7-24 documents R57 is severely cognitively impaired. R57's MDS (Minimum Data Set) assessment dated [DATE] documents R57 had no behavioral symptoms, hallucinations, delusions, or any behaviors that put R57 or others at risk for injury. R57's Progress Notes dated 11-28-23 at 5:45 PM documents R57 was experiencing word salad, restlessness, and increased confusion. R57's Progress Notes dated 12-1-23 at 11:13 AM documents R57 was experiencing increased confusion and restlessness and was complaining of dizziness. This same note documents R57's urine was dark amber in color. R57's Health Status Note dated 12-1-23 at 12:38 AM documents EMS (Emergency Medical Services) was called for transport due to R57 having an altered mental status. R57's Health Status Note dated 12-1-23 at 12:52 AM documents R57 was given a Haldol injection to the right deltoid. R57's Health Status Note dated 12-1-23 at 5:15 PM documents R57 returned to the facility from the hospital with orders for Doxycycline 100 mg BID (twice daily) for 10 days for a UTI (Urinary Tract Infection). Upon returning R57 felt warm and had a temperature of 100.6 degrees Fahrenheit. R57's Physician's Progress Note dated 12-1-23 and signed by V7 (Physician) documents, Reason for call: Fever. I (V7) suggested doing a COVID (Coronavirus Disease) test because (R7) got a COVID shot recently, and many people get COVID about 7-10- days post shot. R57's Health Status Note dated 12-2-23 at 1:10 PM documents, (R57) is very anxious and shaky. (R57) had to be assisted with eating lunch. Involuntary jerking noted of hands and legs. Repeatedly trying to get up and go visit with his good friends. Stating they are up in the air. (V7/Physician) here and new order received to restart last dose of Abilify 1 mg every Wednesday and Saturday. Give dose now. Abilify given. R57's Health Status Note dated 12-2-2023 at 2:30 PM documents, (R57) very confused, restless and 145952 Page 2 of 13 145952 05/08/2024 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0605 Level of Harm - Minimal harm or potential for actual harm agitated. Keeps trying to get up on own and gait very unsteady. Wanting to leave facility saying he is going home. (V7/Physician) notified and orders received for Haldol 5 mg IM (Intramuscularly) now for restlessness and agitation. The facility's COVID Testing Log documents R57 tested positive for COVID on 12-5-23. Residents Affected - Few On 5-5-24 from 9:10 AM through 10:15 AM R57 was sitting in a recliner in his room. R57 exhibited no behaviors during this time. On 5-6-24 at 8:10 AM through 8:43 AM R57 was in a wheelchair in the dining room. R57 was pleasant and had not behaviors during this time. On 5-07-24 at 01:42 PM V5 (CNA) stated, (R57's) only behavior is he tries to stand up and down continuously, (R57) does not have any verbal or physical behaviors. On 5-7-24 at 1:47 PM V3 (MDS Coordinator) stated, When (R57) had signs of a UTI (Urinary Tract Infection) and was COVID positive during the timeframe and was anxious and trying to stand up unassisted. That is when (R57's) Abilify was re-started. (R57) was given Haldol injections due to him being agitated and trying to get up without assistance. Based on observation, interview, and record review the facility failed to ensure residents were free of chemical restraints for three of nine residents (R27, R32, R57) reviewed for anti-psychotic medication use in the sample of 35. Findings include: The facility's Abuse Policy dated 1-9-24 documents, Chemical restraints are not used. The facility's Psychotropic Medications Protocol Chemical Restraints dated 5-16-22 documents, Chemical restraints will not be used to limit or control resident behavior for the convenience of staff. 1. On 5/5/24 at 10:50 AM, R27 was in his room lying in bed. R27 stated he is doing ok. R27 was not displaying any behaviors. On 5/7/24 at 2:30 PM, V12 (Licensed Practical Nurse) entered R27's room to complete wound care. R27 was sleeping off and on throughout the treatment and V12 stated You've been sleepy today. R27 was cooperative with care and was not displaying any behaviors. R27's care plan, dated 2/27/24, documents R27 is on an antipsychotic. He takes Haloperidol (antipsychotic medication) one milligram (mg) by mouth every 12 hours as needed for Unspecified Psychosis not due to a substance or known physiological condition. R27's electronic list of medical diagnoses documents R27 has the following diagnoses: Alzheimer's Disease, Unspecified Dementia without behavioral disturbance, Anxiety, Major Depressive Mood disordersingle episode, Insomnia, and Unspecified Psychosis not due to a substance or known physiological condition. R27's Medication Administration sheet, dated 4/1/24-4/30/24, documents R27 had an order for Haloperidol Oral tablet 1 mg. Give 1 mg by mouth every 12 hours for increased behaviors related to 145952 Page 3 of 13 145952 05/08/2024 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Unspecified Psychosis not due to a substance or known physiological condition. This order has a start date or 4/1/24 and a discontinue date of 5/6/24. R27 current Physician Order sheet, dated 5/8/24, documents R27 has an order for Haloperidol Oral tablet 1 mg. Give 1 mg by mouth every 12 hours for increased behaviors related to Unspecified Psychosis not due to a substance or known physiological condition, for 60 days. This order has a start date of 5/6/24. R27's electronic medical record for Incident Descriptions, documents R27 suffered an unwitnessed fall on 2/24/24, 3/18/24, 4/9/24, and 4/28/24. R27's nursing progress notes, documented by V15 (Licensed Practical Nurse) and dated 3/31/2024 at 3:02 PM, documents (R27) was observed trying to get out of recliner unassisted. When staff approached him he became combative and started accusing staff of giving him medication that was not ordered. He began trying to pull out his catheter saying he needs to go to the bathroom to urinate and yelling at staff. This nurse sat with him and explained that his catheter is in place and that it was collecting his urine. He asked to see the bag. Once it was shown to him, he calmed down until he tried to get up again. This nurse explained that he was confused and asked if he was feeling anxious. He replied yes. Call was placed to (V13, R27's spouse) and she asked that we call hospice to either increase the dose or frequency of Ativan (anti-anxiety medication). Call was placed to hospice to make the request. (V12, Licensed Practical Nurse) called (V7, R27's Physician) to get the order and she ordered that we should try to give a dose of Haldol (antipsychotic medication) at this time. Medication administered at this time. R27's progress notes for 3/31/24 do not document any other behavior charting on this date. R27's Psychotropic Medication informed consent, dated 3/31/24, documents R27's medication consent is needed for Haldol (Haloperidol) 1 mg by mouth every 12 hours for Psychosis. On 5/7/24 at 11:00 AM, V3 (Minimum Data Set coordinator) stated (R27's) consent is for 3/31/24 because that is when it was increased. Prior to that the Haldol was ordered as needed. R27's Behavior Progress note, dated 4/9/24 at 4:23 PM, documents Behaviors: anxious, yelling at staff, trying to get up without assistance. Summary: resident noted to be trying to get out of chair without assistance and yelled at staff when they tried to help. R27's Behavior Progress note, dated 4/13/2024 at 7:04 PM, documents Behaviors: anxious trying to get up without assistance. Summary: resident attempting to get up without assistance. R27's Nursing Progress Note, dated 4/13/2024 at 8:48 PM, documents R27 was displaying a behavior of trying to get out of his chair to use the bathroom. On 5/7/24 at 11:20 AM, V14 (Social Services Director, Licensed Practical Nurse) confirmed he is the person who is in charge of resident behaviors. V14 stated (R27) is an anxious person, always. He was admitted in February on Hospice. They (staff) are also considering (R27) getting up without assistance a behavior because he has had several falls. So we are tracking to make sure he isn't getting up by himself. On 5/7/24 at 11:35 AM, V3 stated R27's Haldol order was changed on 3/31/24 and was then made scheduled for every 12 hours. I know it's an issue that it was increased for the behavior of trying to get 145952 Page 4 of 13 145952 05/08/2024 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0605 up. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 145952 Page 5 of 13 145952 05/08/2024 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 - Some 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** 2. R32's Psychopharmacological Medication Flow Sheet documents R32's Seroquel (anti-psychotic medication) was decreased on 12/12/23 from 12.5 mg (milligram) daily on Mondays, Wednesdays, and Fridays to 12.5 mg on Mondays and Fridays only for the diagnosis of Psychosis. R32's Psychopharmacological Medication Flow Sheet documents R32's Seroquel was increased to 12.5 mg daily on 1/10/24 for the diagnosis of Psychosis. R32's Order Summary Report dated 5/5/24 documents R32 has the diagnoses of Psychotic Disorder with Delusions and Alzheimer's Disease. This same Order Summary Report documents R32 has been receiving Seroquel at 12.5 mg daily since 1/10/24 for the diagnosis of Psychosis. R32's BIMS (Brief Interview of Mental Status) dated 4/11/24 documents R32 is severely cognitively impaired and has no behaviors that put him at risk of harm to themselves or others. R32's Health Status Note dated 12/31/23 documents at approximately 8:00 PM R32 was observed face down on the floor in the hallway with the wheelchair behind him. R32 had laceration to the bridge of his nose and nares with active bleeding. R32 stated he, wanted to get up. Prior to change in elevation R32 was in the hallway by nurses' office conversing with another peer with staff in hallway. R32 refused to go to bed at 7:45 PM when asked if he was ready for bed and he said not yet and pointed at another resident with whom he had been conversing with. R32 was combative with staff when staff attempted to push his wheelchair down the hallway towards his room at approximately 6:30 PM. R32's Progress Notes dated 12/31/23 at 10:29 PM documents R32 was being treated at the emergency room for a fractured nose. R32's Health Status Note dated 1/10/24 at 2:32 PM documents R32 received a new order to increase Seroquel to 12.5 mg daily related to increased restlessness and agitation. R32's Psychotropic Medication Review dated 4/11/24 documents R32's non-pharmacological interventions are effective in treating R32's behaviors related to Psychotic Disorder with delusions. On 5/5/24 at from 9:15 AM through 11:43 AM R32 was sleeping in a low bed with fall mats on the floor beside both sides of the bed. On 05/05/24 at 9:41 AM V4 (CNA/Certified Nursing Assistant) stated, (R32) moans and pushes us away during cares. That is really his only behaviors. On 05/07/24 at 01:42 PM V5 (CNA) stated, (R32's) behaviors that I am aware of is that he moans during cares. (R32) does not have any other behaviors. On 05/06/24 at 08:42 AM V6 (LPN/Licensed Practical Nurse) stated, (R32) gets combative with cares. and resistive with cares. (R32) has no verbal or physical behaviors towards self or others except during cares. 145952 Page 6 of 13 145952 05/08/2024 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 - Some On 05/07/24 at 11:47 AM V3 (MDS Coordinator) stated, The only reason (R32) got his Seroquel increased to 12.5 mg daily on 1-10-24 was because he fell out of his wheelchair and face planted. (R32) does not have behaviors to warrant the use of Seroquel. 3. R54's Order Summary Report dated 5/5/24 documents R54 is receiving the following dual anti-psychotic medications for the diagnosis of Moderate Dementia with Psychotic Disturbance: 12/6/23 Olanzapine 7.5 mg every morning and 10 mg at bedtime daily. 11/10/23 Seroquel 12.5 mg at bedtime daily and 50 mg twice times daily. R54's Psychotropic Medication Reviews dated 4/4/24 documents R54's non-pharmacological behavioral interventions for the use of Olanzapine and Zyprexa are effective. R54's current Anti-Psychotic plan of care does not include justification for the use of dual anti-psychotic medications to treat R54's behaviors associated with Dementia with Psychotic Disturbance. R54's Progress Note dated 2/20/24 and signed by V8 (Psychiatric Mental Health Nurse) documents, Behavior/Attitude: Pleasant and Cooperative. Nursing home documentation documents doing well. Reports sleeping well and able to go on outings. On 05/05/24 at 9:41 AM V4 (CNA/Certified Nursing Assistant) stated, (R54) does not have behaviors. On 05/07/24 at 01:42 PM V5 (CNA) stated, (R54) refuses cares at times. If we re-approach her it helps with (R54's) behaviors. On 05/06/24 at 08:42 AM V6 (LPN) stated, (R54) gets verbal with staff. (R54) has no other verbal or physical behaviors. On 05/07/24 at 11:47 AM V3 (MDS Coordinator) stated, (R54) receives two anti-psychotics for Dementia with Psychosis and does not have justification for the use of two anti-psychotics. (R54) really does not have behaviors. 4. R57's Physician's Orders and Psychopharmacological Medication Flow Sheet documents R57's Abilify (Anti-Psychotic Medication) 1 mg given twice weekly on Wednesdays and Saturdays for the diagnosis of Dementia with Psychosis was discontinued on 11/28/23. R57's Physician's Orders and Psychopharmacological Medication Flow Sheet dated 12/2/23 documents R57's Abilify 1 mg given twice weekly on Wednesdays and Saturdays for the diagnoses of Dementia with Psychosis was restarted. R57's Physician's Orders and Psychopharmacological Medication Flow Sheet dated 1/26/24 documents R57's Abilify was increased to 5 mg daily for the diagnosis of Dementia with Psychosis. R57's Order Summary Reports dated 1/26/24 through 5/6/24 documents R57's Abilify has remained the same dose of 5 mg daily for the diagnosis of Dementia with Psychosis. R57's BIMS (Brief Interview of Mental Status) dated 3/7/24 documents R57 is severely cognitively impaired. R57's MDS (Minimum Data Set) assessment dated [DATE] documents R57 had no behavioral symptoms, 145952 Page 7 of 13 145952 05/08/2024 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0758 hallucinations, delusions, or any behaviors that put R57 or others at risk for injury. Level of Harm - Minimal harm or potential for actual harm R57's Psychotropic Medication Review Assessments dated 3/7/24 documents R57's non-pharmacological interventions are effective for treating R57's targeted behaviors for the use of Abilify which include delusions, anxiousness, anxiety, and restlessness. Residents Affected - Some R57's Progress Notes dated 11/28/23 at 5:45 PM documents R57 was experiencing word salad, restlessness, and increased confusion. R57's Progress Notes dated 12/1/23 at 11:13 AM documents R57 was experiencing increased confusion and restlessness and was complaining of dizziness. This same note documents R57's urine was dark amber in color. R57's Health Status Note dated 12/1/23 at 12:38 AM documents (EMS) Emergency Medical Services was called for transport due to R57 having an altered mental status. R57's Health Status Note dated 12/1/23 at 12:52 AM documents R57 was given a Haldol injection to the right deltoid. R57's Health Status Note dated 12/1/23 at 5:15 PM documents R57 returned to the facility from the hospital with orders for Doxycycline 100 mg BID (twice daily) for 10 days for a UTI (Urinary Tract Infection). Upon returning R57 felt warm and had a temperature of 100.6 degrees Fahrenheit. R57's Physician's Progress Note dated 12/1/23 and signed by V7 (Physician) documents, Reason for call: Fever. I (V7) suggested doing a COVID (Coronavirus Disease) test because (R7) got a COVID shot recently, and many people get COVID about 7-10- days post shot. R57's Health Status Note dated 12/2/23 at 1:10 PM documents, (R57) is very anxious and shaky. (R57) had to be assisted with eating lunch. Involuntary jerking noted of hands and legs. Repeatedly trying to get up and go visit with his good friends. Stating they are up in the air. (V7/Physician) here and new order received to restart last dose of Abilify 1 mg every Wednesday and Saturday. Give dose now. Abilify given. R57's Health Status Note dated 12/2/23 at 2:30 PM documents, (R57) very confused, restless and agitated. Keeps trying to get up on own and gait very unsteady. Wanting to leave facility saying he is going home. (V7/Physician) notified and orders received for Haldol 5 mg IM (Intramuscular) now for restlessness and agitation. R57's Health Status Note dated 12/2/23 at 2:30 PM documents, (R57) very confused, restless, and agitated. Keeps trying to get up on own and gait very unsteady. Wanting to leave facility saying he is going home. (V7) notified and orders received for Haldol 5 mg IM now for restlessness and agitation. The facility's COVID Testing Log documents R57 tested positive for COVID on 12/5/23. On 5/5/24 from 9:10 AM through 10:15 AM R57 was sitting in a recliner in his room. R57 exhibited no behaviors during this time. On 5/6/24 at 8:10 AM through 8:43 AM R57 was in a wheelchair in the dining room. R57 was pleasant and had not behaviors during this time. 145952 Page 8 of 13 145952 05/08/2024 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0758 Level of Harm - Minimal harm or potential for actual harm On 05/05/24 at 9:41 AM V4 (CNA/Certified Nursing Assistant) stated, (R57) cusses at staff and gets anxiety. (R57) does not have any other behaviors. On 05/07/24 at 01:42 PM V5 (CNA) stated, (R57's) only behavior is he tries to stand up and down continuously, (R57) does not have any verbal or physical behaviors. Residents Affected - Some On 05/06/24 at 08:42 AM V6 (LPN) stated, (R57) has no behaviors at all. On 05/07/24 at 11:47 AM V3 (MDS Coordinator) stated, (R57) has no diagnosis or behaviors to justify the use of his Abilify. When (R57) had signs of a UTI and was COVID positive during the timeframe that (R57's) Abilify was re-started, (R57) was given Haldol injections due to him being agitated and trying to get up without assistance. 5. R62's Psychopharmacological Medication Flow Sheet documents R62's Seroquel was decreased on 3/21/24 from 75 mg BID (twice daily) to 50 mg BID due to the diagnosis of Dementia with Visual Hallucinations. R62's Psychopharmacological Medication Flow Sheet documents R62's Seroquel was increased on 3/28/24 from 50 mg BID (twice daily) to 75 mg BID due to the diagnosis of Dementia with Visual Hallucinations. R62's Progress Notes dated 3/21/24 (reduction date of Seroquel) through 3/28/24 (increase date of Seroquel) document R62 was experiencing behaviors of pacing, crying, increased wandering, looking for her husband, and tearfulness. These same Progress Notes do not include effectiveness of non-pharmacological interventions attempted. R62's Order Summary Sheets dated 5/4/24 documents R62 has remained on Seroquel 75 mg BID since 3-28-24. R62's Psychotropic Medication Review dated 2/27/24 documents R62 receives Seroquel for the diagnosis of Dementia with Psychotic Disturbance and non-pharmacological interventions are effective for the behaviors associated with the diagnosis of Dementia with Psychotic Disturbance. R62's BIMS dated 11/30/23 documents R62 is severely cognitively impaired. On 05/05/24 at 9:41 AM V4 (CNA/Certified Nursing Assistant) stated, (R62) cries a lot and thinks she runs this place (the boss). (R62) does not have any other behaviors or physical behaviors. On 05/07/24 at 01:42 PM V5 (CNA) stated, (R62) will tell us 'No' when we try to do cares with her. If we re-approach her it usually works. (R62) does not have any other behaviors. On 05/06/24 at 08:42 AM LPN (V6/LPN) stated, (R62) has no physical behaviors. (R62) screams at staff. (R62) does not scream at other residents. (R62) is very easily re-directed. On 05/07/24 at 11:47 AM V3 (MDS Coordinator) stated, (R62's) Seroquel was increased on 3-28-24 due to (R62) having increased crying and wandering. Increased crying and wandering do not justify the increase of (R62's) Seroquel. The diagnosis of Dementia with Psychosis does not justify the use of (R62's) Seroquel. 145952 Page 9 of 13 145952 05/08/2024 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0758 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to document a diagnosis and target behaviors to warrant the use of anti-psychotic medications, and failed to treat underlying conditions prior to initiating and increasing anti-psychotic medication doses for six of nine (R27, R32, R54, R57, R62, and R65) reviewed for anti-psychotic medication use with the diagnosis of Dementia or Alzheimer's Disease in the sample of 35. Residents Affected - Some Findings include: The facility's Antipsychotic's policy dated 04/2015 documents, 1.) Diagnosis alone does not warrant the use of anti-psychotic medications. The following criteria also needs to be met: a) The behavioral symptoms present a danger to the resident or others and one or both of the following: b) The symptoms are due to mania or psychosis. c) Behavioral interventions have been attempted and documented in the care plan. 2.) Enduring Conditions: Antipsychotic medications may be used to treat an enduring condition (non-acute, chronic, or prolonged). Monitoring must ensure that the behavioral symptoms are: a) Not due to a medical condition or problem that can be expected to improve or resolve as the condition is treated. AND b) Not due to environmental stressors. AND c) Not due to psychological stressors. AND d) The condition is persistent, other approaches have been attempted and failed, and the quality of life is negatively affected by the behavioral symptoms. 1. On 5/5/24 at 10:50 AM, R27 was in his room lying in bed. R27 stated he is doing ok. R27 was not displaying any behaviors. On 5/7/24 at 2:30 PM, R27 was laying in his bed and sleeping off and on throughout a wound treatment. R27 was cooperative with care and was not displaying any behaviors. R27's care plan, dated 2/27/24, documents R27 is on an antipsychotic. He takes Haloperidol (antipsychotic medication) one milligram (mg) by mouth every 12 hours as needed for Unspecified Psychosis not due to a substance or known physiological condition. R27's electronic list of medical diagnoses documents R27 has the following diagnoses: Alzheimer's Disease, Unspecified Dementia without behavioral disturbance, Anxiety, Major Depressive Mood disordersingle episode, Insomnia, and Unspecified Psychosis not due to a substance or known physiological condition. R27's Medication Administration sheet, dated 4/1/24-4/30/24, documents R27 had an order for Haloperidol Oral tablet 1 mg. Give 1 mg by mouth every 12 hours for increased behaviors related to Unspecified Psychosis not due to a substance or known physiological condition. This order has a start date or 4/1/24 and a discontinue date of 5/6/24. R27 current Physician Order sheet, dated 5/8/24, documents R27 has an order for Haloperidol Oral tablet 1 mg. Give 1 mg by mouth every 12 hours for increased behaviors related to Unspecified Psychosis not due to a substance or known physiological condition, for 60 days. This order has a start date of 5/6/24. R27's nursing progress notes, documented by V15 (Licensed Practical Nurse) and dated 3/31/2024 at 3:02 PM, documents (R27) was observed trying to get out of recliner unassisted. When staff approached him he became combative and started accusing staff of giving him medication that was not ordered. He began trying to pull out his catheter saying he needs to go to the bathroom to urinate and yelling at staff. This nurse sat with him and explained that his catheter is in place and that it was 145952 Page 10 of 13 145952 05/08/2024 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 - Some collecting his urine. He asked to see the bag. Once it was shown to him, he calmed down until he tried to get up again. This nurse explained that he was confused and asked if he was feeling anxious. He replied yes. Call was placed to (V13, R27's spouse) and she asked that we call hospice to either increase the dose or frequency of Ativan (anti-anxiety medication). Call was placed to hospice to make the request. (V12, Licensed Practical Nurse) called (V7, R27's Physician) to get the order and she ordered that we should try to give a dose of Haldol (antipsychotic medication) at this time. Medication administered at this time. R27's progress notes for 3/31/24 do not document any other behavior charting on this date. R27's Behavior Tracking sheets for April 2024 document R27 is being monitored for behaviors of Change in Mood, Anxious, Behaviors of Psychosis, Sad Mood, and Tearful. R27's Behavior Progress note, dated 4/9/24 at 4:23 PM, documents Behaviors: anxious, yelling at staff, trying to get up without assistance. Summary: resident noted to be trying to get out of chair without assistance and yelled at staff when they tried to help. R27's Behavior Progress note, dated 4/13/2024 at 7:04 PM, documents Behaviors: anxious trying to get up without assistance. Summary: resident attempting to get up without assistance. R27's Nursing Progress Note, dated 4/13/2024 at 8:48 PM, documents R27 was displaying a behavior of trying to get out of his chair to use the bathroom. On 5/7/24 at 11:20 AM, V14 (Social Services Director, Licensed Practical Nurse) confirmed he is the person who is in charge of resident behaviors. V14 stated (R27) is an anxious person, always. He was admitted in February on Hospice. They (staff) are also considering (R27) getting up without assistance a behavior because he has had several falls. So we are tracking to make sure he isn't getting up by himself. At this time V14 confirmed that R27's behaviors are not psychotic in nature. V14 stated He isn't aggressive towards other residents or a harm to himself. (R27) has aggression towards staff. 6. On 5/5/24-5/8/24, random observations were made of R65, in the dining room, R65's room, and common areas and R65 did not exhibit any behaviors. R65 was calm, pleasant, and enjoyed visiting with staff and peers. R65's Minimum Data Set assessment dated [DATE], documents R65 has moderately impaired cognition with a Brief Interview for Mental Status score of 11 out of 15; has no presence of behaviors; and takes a High-Risk Drug classified as an Antipsychotic. R65's current computerized physician orders documents R65 has a diagnosis of Dementia and is on Seroquel (antipsychotic medication) 12.5 mg by mouth two times daily for a diagnosis of unspecified psychosis not due to a substance or known physiological condition. R65's Psychotropic Medication Reviews dated 3/14/24, documents R65's non-pharmacological behavioral interventions are effective. R65's Most recent Care Plan does not include justification for the use of anti-psychotic medication to treat R65's behaviors associated with Alzheimer's or related dementia. This same care plan does not document R65's specific target behaviors to justify the use of an antipsychotic medication. 145952 Page 11 of 13 145952 05/08/2024 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 - Some R65's Behavior Tracking forms dated November 2023 through April 2024, documents R65 has no behaviors to justify the use of an antipsychotic medication. On 5/8/24 at 10:19AM, V3 (Minimum Data Set coordinator) stated R65 was admitted on Seroquel with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety on 6/28/23. V3 stated R65 has no behaviors towards anyone but staff. V3 stated R65 does not have behaviors that justified the use of Seroquel. V3 stated R65 really doesn't have behaviors like she did when she was first admitted . I am wanting to get (R65) off the Seroquel. V3 stated R65 is easily redirected, and non-pharmacological interventions were effective when R65 exhibited yelling or cussing. On 5/8/24 at 11:01AM, V10 (Infection Preventionist /LPN) stated R65 is cooperative with cares, has moments of aggravation when in a loud area, such as in the dining room, and will yell shut up! V10 stated R65 is easily redirected after talking to R65 or by taking R65 back to their room. On 5/8/24 at 10.57AM, V11 (CNA) stated (R65) usually has no behaviors but occasionally will yell shut the F*** up or will say Is that necessary? 145952 Page 12 of 13 145952 05/08/2024 Beardstown Health & Rehab Ctr 8306 St Lukes Drive Beardstown, IL 62618

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure Enhanced Barrier Precautions were followed and care planned for residents who are at a high risk for infection for two of seventeen residents (R27, R29) reviewed for Infection Control in the sample of 35. Residents Affected - Few Findings include: The facility's Enhanced Barrier Precautions protocol sign (undated) documents Everyone must clean their hands, including before entering and when leaving the room. Provides and Staff must also wear gloves and a gown for the following high-contact resident care activities: Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use (Central Line, Urinary Catheter, Feeding tube, tracheostomy), Wound Care: Any skin opening requiring a dressing. 1. R27's Physician Order sheet, dated 5/8/24, documents R27 has an order for an indwelling urinary catheter to be changed monthly. This same order sheet documents R27 has wound treatment orders to be completed on the coccyx daily and R27's left second toe daily and as needed. R27's current care plan does not document a plan of care for Enhanced Barrier Precautions. On 5/5/24 at 10:50 AM, R27 was in his room laying in bed. R27 stated he is doing ok. R27's urinary catheter drainage bag was hanging from R27's bed frame and contained yellow urine. R27's door to enter the room contained a sign that documents Stop and listed the Enhanced Barrier Precaution procedure. On 5/7/24 at 2:30 PM V12 (Licensed Practical Nurse) entered R27's room to perform a wound treatment to R27's left second toe. R27's door contained a sign for Enhanced Barrier Precautions. V12 performed hand hygiene and applied gloves to complete R27's wound care. When the wound treatment was complete, V12 removed her gloves and placed a clean sock on R27's foot with bare hands. Throughout the dressing change V12 did not wear a gown and when applying a sock to R27's foot V12 did not wear gloves or a gown. 2. On 5/6/24 at 12:15 p.m., R29 was sitting up in her bed talking to V12 (Licensed Practical Nurse) while V12 was administering a medication through R29's gastrostomy tube (g-tube). Throughout the medication administration, which included water flushes and connecting the tubing to the g-tube, V12 did not wear a gown when accessing R29's g-tube. R29's current care plan does not document a plan of care for Enhanced Barrier Precautions. On 5/8/24 at 11:15 AM, V2 (Director of Nursing) confirmed the facility cannot provide an updated infection control policy with the new Enhanced Barrier Precaution protocol. V2 stated Enhanced Barrier Precautions should be implemented when a resident has a (indwelling urinary catheter), Pressure Ulcer and Feeding Tubes. Staff should wear gowns and gloves when providing high contact direct resident care. V2 confirmed V12 should have been wearing the gloves and a gown during R27's dressing change and R29's feeding tube medication administration. 145952 Page 13 of 13