Health inspection·February 24, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop a plan of care for one of 17 residents (R1) reviewed for care plans in the sample of 26. Findings include: The facility's Care Plans, Comprehensive Person-Centered, revised March 2022, states, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: 1. services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The facility's Wandering and Elopements Policy, reviewed 7/2/21, states, 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Elopement is considered off facility property. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses to include but not limited to: Major Depressive Disorder; History of Falling; Altered Mental Status; Anxiety Disorder; Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance. R1's Elopement Evaluation, dated 12/22/22, documents R1 as at risk for elopement. This same evaluation documents R1 wanders and has expressed the desire to go home, packed belongings to go home, or stayed near an exit door. R1's current Order Summary Report documents R1 an order, with a start date of 12/23/22 to check R1's electronic monitoring device and to test the battery every shift. On 2/21/23 and 2/24/23, R1 was observed sitting in R1's wheelchair with an electronic monitoring device noted to R1's right wrist. Page 1 of 6 146033 146033 02/24/2023 Elms, The 1212 Madelyn Avenue Macomb, IL 61455

F 0656 Level of Harm - Minimal harm or potential for actual harm R1's Behavior Note on 12/21/22 at 10:39 PM documents R1 was found wandering in R1's wheelchair up by the business office. R1's Behavior Note on 12/22/22 at 9:55 PM documents that due to R1's wandering and behaviors, an electronic monitoring device was applied to R1's right wrist. Residents Affected - Few R1's Behavior Note on 1/4/23 at 8:00 PM documents R1 wandering in R1's wheelchair and R1 being tearful and talking to self. R1's Behavior Note on 1/18/23 at 10:00 PM documents R1 got herself up and fully dressed and in R1's wheelchair. This same note documents R1 as being very anxious, thinks it is morning and thinks R1 is going home. R1's Behavior Note on 2/17/23 at 7:07 PM, states, (R1) exit seeking. (R1) told where her room is. (R1) went toward A-Hall Emergency Exit. (R1) states, 'I'm not staying here.' (R1) has angry/loud tone. R1's Health Status Note on 2/21/23 at 2:44 PM documents R1 told CNA/Certified Nursing Assistant that she is packing to leave in the morning and R1 asked for garbage bags to put her belongings in. As of 2/21/23 at 12:00 PM, R1's current Care Plan did not contain any documentation or interventions regarding R1's elopement risk, wandering behaviors, exit seeking behaviors or electronic monitoring device. On 2/23/23 at 12:47 PM, V2 (Director of Nursing) and V9 (Care Plan Coordinator) stated that R1's risk for elopement and history of wandering and exit seeking behavior was not added to R1's Care Plan prior to 2/21/23. V9 stated, I am just going to be honest, we added that to R1's Care Plan a couple days ago when we realized it got missed. V2 stated, It was right around the holidays, and we had COVID in the building, so it just got overlooked. It's on there now. At this time, V9 stated that R1's electronic monitoring device order was also updated on 2/21/23 because they realized the wrong number was written for which device R1 had. V9 stated that R1 has had the electronic monitoring device in place since 12/22/22. 146033 Page 2 of 6 146033 02/24/2023 Elms, The 1212 Madelyn Avenue Macomb, IL 61455

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 provide an appropriate indication for use of an antipsychotic medication and failed to identify specific target behaviors for three residents (R33, R38, R42) with a diagnosis of Dementia of five residents reviewed for unnecessary psychotropic medications in the sample of 26. Findings include: Facility Policy/Antipsychotic Medication Use dated July 2022 documents: Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Diagnosis alone does not warrant the use of antipsychotic medication, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; and 1. the symptoms are identified as being due to mania or psychosis (such as auditory, visual or other hallucinations, delusions, paranoia or grandiosity; or 2. behavioral interventions have been attempted and included in the care plan, except in an emergency. 1. Current Physician's Order Summary Report indicates R33 is [AGE] years old and was admitted to the facility 9/07/17 with diagnoses that include Paranoid Schizophrenia, Age-Related Cognitive Decline, Bipolar Disorder and Dementia with other Behavioral Disturbance. Current Order Summary Report and Medication Administration Record indicate R33 receives Seroquel (antipsychotic) 75mg (milligrams) twice daily (date initiated 12/02/22) for Unspecified Dementia with Mood Disturbance and Schizophrenia. Psychoactive Medication Informed Consent dated 5/13/18 indicates consent was given for R33 to receive Seroquel 25mg at bedtime for hallucinations. Consent dated 9/16/18 indicates Seroquel was increased to an additional dose of 12.5mg every am for auditory hallucinations and yelling out. Pharmacy Review dated 11/21/22 indicates a recommendation was made for a GDR (Gradual Dose Reduction) of R33's Seroquel 25mg twice daily and 75mg at bedtime. Review indicates R33's physician declined the reduction due to Aggression and refusing care. Telehealth Psychiatry Nurse Practitioner progress note dated 11/30/22 indicates R33 has a history of Audio/Visual Hallucinations - mostly of a little boy, confusion, combativeness and wandering behaviors. Recent GDR (Gradual Dose Reduction) received and declined at this time. Note indicates R33 has ongoing reports of confusion and agitation, refuses care at times and has noted incident of hitting staff and yelling. Note indicates R33 stated This house is mine and staff reports R33 becomes agitated when there are communication issues between her and staff due to hearing difficulties. 146033 Page 3 of 6 146033 02/24/2023 Elms, The 1212 Madelyn Avenue Macomb, IL 61455

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Current Comprehensive assessment dated [DATE] and 9/12/22 indicates R33 had no psychosis, delusions or hallucinations. On 2/21/23 and 2/23/23 R33 was seen in her room and in the milieu. R33 was unable to answer questions appropriately. On 2/23/23 R33 was sitting up in a chair near the nurses' station with eyes closed, fidgeting and occasionally mumbling. On 2/23/23 at 1:30pm both V10 (Licensed Practical Nurse/LPN) and V11 (Certified Nurse Assistant/CNA) stated that R33's main behavior is being verbal and physically resisting care, combative with staff. V11 stated that R33 may be having increased pain. Progress Notes dated 1/1/23 through 2/23/23 found no incidence of delusions or hallucinations. Multiple notes document combative with care - refusing to get out of bed, refusing meals, refusing medications. Current Care Plan indicates R33 takes Seroquel related to Schizophrenia for behavior management (hallucinations, delusions, paranoia) related to chronic Schizophrenia. Care Plan interventions include monitor/record occurrence of target behavior symptoms (paranoia, hallucinations, delusions, yelling) and document per facility protocol (date initiated 5/15/18). OBRA (Omnibus Budget Reconciliation Act) Screen Part V dated 9/12/17 indicates: Although an item was marked yes on the preceding page, the individual does not need a Level II assessment by this agency because: No treatment for Schizophrenia in 30-40 years; prescribed no medications for mental illness. On 2/21/23 at 12:30pm V12 (Social Service Director/SSD) stated that R33's family reported that R33 was given the Schizophrenia diagnosis many years ago after the birth of one of her children. 2. Current Physician's Order Summary Report indicates R38 was admitted to the facility 9/20/18 and has diagnoses that include Schizophrenia, Obsessive Compulsive Disorder and Dementia with other Behavioral Disturbance. Current Order Summary Report and Medication administration Record indicate R38 receives Olanzapine 7.5mg (milligram) at bedtime (date initiated 12/31/21). Psychoactive Medication Informed Consent dated 9/20/18 indicates consent was given for R38 to receive Olanzapine (antipsychotic) 10mg with diagnosis of Schizophrenia to improve mood. Psychoactive Medication Informed Consent dated 2/22/23 indicates consent was given for R38 to receive Olanzapine (no dosage indicated) with diagnosis of Schizophrenia with Proposed Course of Medication is approximately: Prolonged treatment/indefinite. Consent does not indicate target behaviors antipsychotic is being used to treat. Pharmacy Review dated 11/23/22 indicates a recommendation was made for a GDR (Gradual Dose Reduction) of R38's Olanzapine. Review indicates R38's physician declined the reduction due to hallucinations. 146033 Page 4 of 6 146033 02/24/2023 Elms, The 1212 Madelyn Avenue Macomb, IL 61455

F 0758 Level of Harm - Minimal harm or potential for actual harm Telehealth Psychiatry Nurse Practitioner progress note dated 1/30/23 indicates R38 has reported significant symptoms relating to dementia, psychosis, anxiety. Note indicates R38 has a history of auditory hallucinations and delusions in which she was hearing angels talking to her and also had compulsive behaviors of counting toilet papers. Residents Affected - Few Note indicates R38 presented lying in bed pleasant, smiling with continued confusion noted. Note indicates R38 reported happy mood, not much sadness and no evidence of (R38) responding to internal stimuli. Note indicates R38 reports anxiety, memory loss and dementia but reports no depression, no sleep disturbances, no hallucinations and no suicidal thoughts. Telehealth Psychiatry Nurse Practitioner progress note dated 11/30/22 indicates R38 reports no hallucinations, no delusions. Telehealth Psychiatry Nurse Practitioner progress note dated 9/28/22 indicates R38 reports no recent occurrences of hearing angels talking to her and no compulsive behaviors of counting toilet papers. Note indicates R38 identified prayer as something that helps her cope. Current Comprehensive assessment dated [DATE], 10/25/22 and 7/26/22 indicates R38 had no delusions or hallucinations. On 2/21/23 and 2/23/23 R38 was seen in her room and in the milieu, was pleasant and appropriate. On 2/23/23 at 1:30pm both V10 (LPN) and V11 (CNA) stated that R38 really doesn't have any behaviors. Both stated R38 is pleasant and cooperative. Both stated that behaviors are reported to the nurse and only the nurse documents behaviors. Progress Notes dated 1/1/23 through 2/23/23 found no incidence of delusions, hallucinations, distress or any type of inappropriate behavior. Current Care Plan indicates R38 takes routine medication for Schizophrenia and that (R38's mood is managed with Olanzapine. Care Plan does not include target behaviors or non-pharmacological interventions attempted. 3. Current Physician's Order Summary Report indicates R42 was admitted to the facility 3/9/22 with diagnoses that include Anxiety Disorder and Dementia with other Behavioral Disturbance. Current Order Summary Report and Medication Administration Record indicate R42 receives Seroquel 37.5mg at bedtime for Unspecified Dementia with Mood Disturbance Psychoactive Medication Informed Consent dated 4/12/22 indicates consent was given for R42 to receive Seroquel (antipsychotic) 50mg every evening with diagnosis agitation and anxiety. No specific target behaviors are identified in the consent. Psychoactive Medication Informed Consent dated 2/23/23 indicates consent was given for R42 to receive Seroquel (no dose identified) for Expressions or indications of distress/behavioral and psychological symptoms of dementia. 146033 Page 5 of 6 146033 02/24/2023 Elms, The 1212 Madelyn Avenue Macomb, IL 61455

F 0758 Level of Harm - Minimal harm or potential for actual harm Pharmacy Reviews dated 5/2/22 and 11/30/22 indicates a recommendation was made for a GDR (Gradual Dose Reduction) of R42's Seroquel. Review indicates R38's physician declined the reduction due to: R42's target symptoms returned or worsened after most recent GDR attempt within facility thereby continuing to pose a danger to resident or others. Residents Affected - Few No documentation was found or presented to indicate R42 was a danger to self or others. Current Comprehensive assessment dated [DATE], 11/1/22 and 9/6/22 indicates R42 had no delusions or hallucinations. On 2/21/23 and 2/23/23 R42 was seen in her room and in the milieu, was smiling, pleasant and appropriate. On 2/23/23 at 1:30pm both V10 (LPN) and V11 (CNA) stated that R42 really doesn't have any behaviors. Both stated R42 is pleasant and cooperative. Both stated that behaviors are reported to the nurse and only the nurse documents behaviors. On 2/23/23 at 9;45am V2 (Director of Nursing) stated that R42 had behaviors after being admitted to the facility from home. V2 stated that R42 had difficulty adjusting to the facility. Progress Notes dated 1/1/23 through 2/23/23 found no incidence of delusions, hallucinations, distress except for note dated 2/22/23 at 12:30am that indicates R42 was wandering around in/out of other resident rooms with increased confusion and disorientation. Current Care Plan indicates R42 uses Seroquel related to Dementia with Behavioral Disturbance. No target behaviors are identified in R42's care plan. On 2/23/23 at 11:15am V3 (Assistant Director of Nursing) stated that they thought the diagnoses were appropriate for the antipsychotic medications, however it has been difficult to get the reductions because the physicians don't want the medications to be reduced. 146033 Page 6 of 6