Health inspection·August 3, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to document appropriate indications to warrant the use of an antipsychotic medication (R46) and attempt a gradual dose reduction (R19) for 2 of 5 residents reviewed for unnecessary medication in a sample of 23. Findings include: A Psychotropic Medication policy dated 11/28/17 gives as its intent, Residents are free from unnecessary psychotropic medication use. This policy states that antipsychotic medication may be indicated for use if behavioral symptoms present a danger to the resident or others; expressions or indications of distress that are significant distress to the resident; if not clinically indicated, multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which are presenting a danger or significant distress; and /or a gradual dose reduction (GDR) was attempted, but clinical symptoms returned. In addition, this policy states that a GDR must be attempted annually, unless contraindicated. 1. R46's list of current diagnoses includes Unspecified Dementia, Unspecified Severity, with other behavioral disturbance, Depression, and Anxiety disorder. R46's physician's order (POS) dated 6/20/23 documents R46 was prescribed the antipsychotic medication Seroquel 25 mg (milligrams) two times daily for the diagnosis of Unspecified Dementia, Unspecified Severity, with other behavioral disturbance. R46's physician's visit notes dated 6/2/23 instructs staff to use the diagnosis, Dementia (with) behaviors for her Seroquel. R46's Physical Device/Psychoactive Medication Initial and Quarterly Evaluation dated 6/20/23 documents R46 has the mental status of being alert, disoriented, with a short attention span. This same evaluation documents that R46 has the emotional, environmental, and social considerations of toileting difficulties, dependence on staff for turning and repositioning, and feelings of anger, loneliness, and abandonment. This same evaluation includes an area for defined recommendations/alternatives and individualized alternatives to administering psychoactive medications to R46, however, the only recommendation made was for family visits which, this evaluation documents, have been effective as an alternative to medications. In addition, R46's psychoactive medication evaluation documents the indication to warrant R46's use of an antipsychotic medication as dementia with behavior disorder. (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 3 Event ID: 146042 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 146042 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE H & J Vonderlieth Lvg Ctr, The 1120 North Topper Drive Mount Pulaski, IL 62548 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)