Health inspection·June 9, 2023

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation the facility failed to provide nonpharmacological interventions for one of three resident (R33) reviewed Psychotropic medications in the sample of 18. Residents Affected - Few Findings Include: R33's Minimum Data Set, (MDS), dated [DATE] documents, R33's cognitive skills for daily decision making is severely impaired, and she rarely makes decisions. R33's MDS also, documents R33 has diagnoses of Schizophrenia, Alzheimer's, and Dementia. R33's Behavior Tracking for the month of May documents, R33 has history of mental illness requiring the use of Antipsychotic medications - monitor for any episodes, such as yelling and crying Goal: maintain absence of behavior/mood swings. Behavior tracking was not done every day. Interventions: 1. report any episodes to nurse 2. encourage activities 3. Provide consistent and clear feedback in non-threatening behavior. (No specific interventions for psychotic behavior were listed on the behavior tracking, and no specific mental illness behaviors were listed.) On 06/07/23 02:24 PM V18 Certified Nursing Assistant, (CNA), She sees things that are not there reaching on the table for things. On 06/07/23 at 2:26 PM V19 CNA yes, she is always reaching for things that are not there She is always talking to people. On 06/07/23 at 2:35 PM V20 Licensed Practical Nurse, (LPN), No Psychosis I haven't noticed her talking to self. She is usually sleeping. On 06/07/23 at 2:40 PM V11 CNA, she talks to self and grabs things out of the air that are not there. She talks to herself. (None of them had any interventions for the above behaviors). On 06/08/24 at 12:50 AM V10 LPN stated, it depends on the day talking to her baby doll in her room. Sometimes she is talking to herself. 90% of the time she can be redirected or reproached. She has a diagnosis of Dementia. She does have verbal aggression not toward anybody. On 6/8/23 at 12:52 PM V22 CNA stated, no behaviors with me. she has fits with other aides. We try to do an activity or watch TV (television). Sometimes it works. V3 MDS stated, I saw it (the schizophrenia diagnosis) in the computer. I don't know how it got there. When she came, she had behavior. V7 CNA Coordinator stated, we just leave her (R33) alone. Let her calm down. She has a baby doll Page 1 of 3 146052 146052 06/09/2023 Alhambra Rehab & Healthcare 417 East Main Street, Box 310 Alhambra, IL 62001

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 06/07/23 11:15 AM R33 is very confused her husband was pushing her around the facility she has a flat affect. 06/07/23 11:50 AM R33 is sitting in the dining room. Mumbling to herself. The facility policy dated 10/1/20 entitled Behavioral Assessment, Intervention, and Monitoring. the facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and Psychosocial well-being in accordance with comprehensive assessment and plan of care. 146052 Page 2 of 3 146052 06/09/2023 Alhambra Rehab & Healthcare 417 East Main Street, Box 310 Alhambra, IL 62001

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview, record review, and observation the facility failed to properly assess before giving a diagnosis of Schizophrenia for the administration of Antipsychotic medications for one of one resident (R33) reviewed for diagnosis without assessment in the sample of 18. Residents Affected - Few Findings Include: R33's Local Hospital Record Adult Hospitalist Service History and Physical dated 4/13/23 documents in part R33 as having diagnoses of Alzheimer's Disease, Dementia in senility without behavioral disturbances, Memory Loss, Depression. R33's Adult Hospitalist Service History does not document a diagnosis Schizophrenia, but her home medications documents Risperidone 1mg (milligrams) take 1.5 tablets nightly at bedtime. The patient (R33) was taking differently take 1mg by mouth nightly at bedtime. R33's Electronic Health Record/ Diagnoses document on 5/25/22 the diagnosis of Schizophrenia was added to her diagnosis list. R33's Electronic Health Record/Physician Order Sheet (POS) dated 11/3/22 documents R33 has an order for Risperidone 0.5mg daily at 12:00 noon. R33's Electronic Health Record POS dated 5/26/23 documents Risperidone 1mg daily at 6:00 PM was added to the resident regimen with the diagnosis of Schizophrenia Unspecified. R33's Electronic Health Record/Antipsychotic drug use: At risk for side effects Care Plan does not document an assessment, goals, or interventions concerning her diagnosis of Schizophrenia. The undated facility policy entitled Physician Services documents the physician will perform pertinent, timely medical assessments prescribe an appropriate medical regimen; provide adequate timely information about the resident's condition and medical needs, visit the resident at appropriate intervals and ensure adequate alternative coverage. The medical director will identify attending physician qualifications and responsibilities based on clinical and regulatory requirements and the recommendations of relevant professional associations. 146052 Page 3 of 3