Inspection·December 15, 2022

F 0656 On 12/15/2022 at 11:30am, V2 (Director of Nursing/DON) said a psychotropic medications should have been addressed in R21 and R23's care plans but it had been missed and not included. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146070 If continuation sheet Page 2 of 4 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 146070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Willows Nursing Center 1600 North Broadway Salem, IL 62881 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)

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. Based on interview and record review the facility failed 1.) to ensure psychotropic medications were used for an appropriate indicated use, 2.) to track target psychiatric symptoms being treated and 3.) to ensure non-duplicate drug therapy is administered for 2 of 4 residents (R21, R23) reviewed for unnecessary psychotropic medication in a sample of 25. Findings Include: 1. According to R21's face sheet R21 was admitted to this facility on 11/21/2021 with the diagnosis of Anxiety, Depression, Insomnia and Dementia among other non-psychiatric diagnosis According to R21's Physician Order Sheet for December 2022, (12/1/2022 through 12/31/2022), R21 was prescribed a second generation antipsychotic medication on 4/13/2022 called Seroquel 25mg by mouth at bedtime for depression. On 7/13/2022 R21 was prescribed another second generation antipsychotic medication called Geodon 20mg by mouth every day for increased agitation and anxiety with increased behavioral problems. On 12/14/2022 at 1:30pm, V2 (Director of Nursing/DON) verified R21 has taken both medications since they were prescribed. 2. According to R23's face sheet, R23 was admitted to this facility on 3/16/2021 with the diagnosis of H/O (History of) Dementia and Behavioral/Psychiatric symptoms of Dementia among other non psychiatric diagnosis. According to R23's Physician Order Sheet for December 2022 (12/1/2022 through 12/31/2022) R23 was prescribed a second generation antipsychotic medication on 3/16/2021 called Seroquel 125mg by mouth, every day related to Anxiety. On 6/23/2022 R23 was prescribed an additional second generation antipsychotic medication called Geodon 20mg by mouth at 5:00pm related to Dementia and Agitation. On 12/14/2022 at 1:30pm, V2 (Director of Nursing/DON) verified R21 has taken both medications since they were prescribed. On 12/15/2022 at 11:30am, V10 (Pharmacist) said he reviews each resident's medication regimen every month and makes recommendations accordingly. V10 said he noticed R23 and R21 both are being prescribed two medications in the same drug classification and this is called duplicate medications regimen. V10 said taking duplicate second generation psychotropic medications doesn't make the medications work better, can have serious cardiac side effects and is actually against federal and state long term care regulations. V10 said he has notified both R23 and R21's doctor and the facility of R21 and R23 not having an appropriate diagnosis for being prescribed psychotropic medications but it has not been addressed as of today. A facility document located in R23's medical record and dated 6/28/2021 shows V10 had sent written notification to R23's doctor and the nursing home concerning R23 being on duplicate antipsychotic medication and the diagnosis of Dementia, Agitation and Anxiety were not appropriate indications for the use of psychotropic medications. V10 said he also sent written notification on 4/25/2021 to R21's physician and the facility concerning R21 being on duplicate drugs and them being used for the inappropriate diagnosis of Agitation/Anxiety with increased behavioral problems and Depression. On 12/14/2022 at 1:30pm, V2 (Director of Nursing) said she could not locate any of V10's recommendations for R21. V2 agreed that V10 had performed monthly reviews of R21's medications, however the facility did not manage to keep track of the documents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146070 If continuation sheet Page 3 of 4 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 146070 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/15/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Twin Willows Nursing Center 1600 North Broadway Salem, IL 62881 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/14/2022 at 1:30pm, V2 (DON) said she knows the facility's nursing staff is supposed to be tracking the symptoms in for which the resident is prescribed psychotropic medications but they have not been doing this and she freely admits it. V2 said she will immediately begin re-educating the staff on this subject and get the practice back in tract. V2 said she was not aware of any residents being on duplicate drug therapies, including antipsychotic medications. V2 said they will do better with the psychotropic medication symptom tracking/monitoring in the future. On 12/14/2022 at 1:30pm, V2 agreed the nursing staff had not followed the facility's Psychotropic Medication policy but should have. A facility policy titled Policy for Administration of Psychotropic Medications (not dated) under the section titled Procedure documents the following Follow the requirements as stated in the Illinois Department of Public Health Administrative Code for assessments, administration, monitoring and dose reduction recommendations for administering, monitoring, reduction and/or discontinuance an psychotropic drug; considered for behavior modification. Under the section titled Documentation it documents the following Document in the resident's medical record the assessments, administration, behavior tracking and interventions and outcome of the medication as directed by the Illinois Department of Public Health Administration code. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146070 If continuation sheet Page 4 of 4