Health inspection·March 17, 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 identify an appropriate indication for administration of an antipsychotic medication for two residents with a diagnosis of Dementia (R31, R42) of three residents reviewed for unnecessary antipsychotic medications in the sample of 18. Findings include: Facility Policy/Psychotropic Medication dated/revised 11/28/17 documents: These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the medical record. Specific condition/medical symptoms alone are not enough to justify pharmalogical use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. Additionally, 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. 1) Physician's Order Summary Report indicates R31 was admitted to the facility 12/31/19 with diagnoses that include Chronic Post Traumatic Stress Disorder, Unspecified Dementia - Unspecified Severity with Other Behavioral Disturbance, Moderate Recurrent Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Unspecified Macular Degeneration. Report indicates Seroquel (antipsychotic) 25mg (milligrams) at bedtime related to Chronic Post-Traumatic Stress Disorder was initially ordered on 1/19/23. MAR (Medication Administration Record) indicates R31 continued to receive Seroquel through 3/15/23. Pre admission Screening dated 1/4/20 indicates R31 was admitted without mental illness or developmental disability. Antipsychotic Medication Consent indicates consent was received to administer Seroquel 25mg for Post-Traumatic Stress Disorder on 1/18/23. Consent indicates medication is used to treat specific conditions, such as Schizophrenia, Delusional Disorder, Schizoaffective Disorder, Acute Psychotic Episodes, Atypical Psychosis, Tourette's Disorder, Huntington's Chorea, Psychotic Mood Disorder, Manic Behavior. Behavior Note dated 1/31/2023 at 7:29pm indicates peer talking on her cell phone propelling herself (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: 146063 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 146063 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Walnut 308 South Second Street Walnut, IL 61376 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)