Health inspection·November 2, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement post fall interventions for one (R1) of three residents reviewed for falls in the sample list of four. Findings include: R1's plan of care dated 8/30/24 documents R1 was admitted to the facility on [DATE]. R1's fall risk assessment dated [DATE] documents R1 has a history of multiple falls and is at high risk for falls. R1's fall investigation report dated 9/19/24 documents R1 slipped in room while self-ambulating at 5:30 PM. This report documents a new intervention of requesting therapy. R1's fall investigation report dated 9/25/24 documents R1 fell attempting to change undergarment at 9:50 AM. This report documents a new intervention to order physical and occupational therapy. R1's plan of care documents a new fall intervention dated 9/25/24 for physical and occupational therapy to evaluate and treat for strengthening. R1's fall investigation report dated 10/21/24 documents R1 fell in the dining room at 11:00 PM. R1's plan of care documents a new fall intervention dated 10/21/24 for physical and occupational therapy to evaluate and treat. On 11/2/24 at 8:48 AM, V13 Occupational Therapy Assistant stated R1 was on therapy for a couple weeks after she was admitted (8/5/24). V13 stated R1 hasn't been on therapy since that time. On 11/2/24 at 9:07 AM, V14 Regional Occupational Therapist stated R1 received therapy from August 5th through August 21st. V14 stated the therapy company did not receive an order to evaluate R1 for therapy in September or October 2024. V14 stated the therapy company has not received orders to evaluate R1 for therapy since R1's admission [DATE]). On 11/2/24 at 9:17 AM, V2 Director of Nursing stated a therapy evaluation was recommended as a new intervention for R1's falls that occurred on 9/19/24, 925/24, and 10/21/24. V2 stated she could not find documentation in R1's medical record that therapy evaluated R1 for physical or occupational therapy. Page 1 of 2 146080 146080 11/02/2024 Countryside Care Center 400 West Grant Street 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. Based on interview and record review the facility failed to develop a plan of care for the use of an antipsycotic medication, implement behavioral interventions, and limit a prn (as needed) antipsychotic medication to 14 days. This failure had the potential to affect one (R1) of three residents reviewed for medications in the sample list of four. Findings include: The facility's Psychotropic Medication Policy with a revision date of 11/2917 documents the care plan will identify target behaviors and will address the problem, approaches and goals to address the behaviors. This policy documents the Behavioral Tracking sheet will be implemented to ensure behaviors are monitored. This policy documents PRN orders for antipsychotic medications have a time limit of 14 days and if the physician or prescribing practitioner wishes to write a new order, they must first evaluate the resident to determine if the new order for the PRN is appropriate. R1's Preadmission Screening and Resident Review (PASRR) screen dated 8/2/24 documents R1 does not have a history of Mental Illness. R1's physician order dated 9/17/24 documents an order for haloperidol (antipsychotic medication) five milligams intramuscularly every 12 hours as needed for increased behaviors. R1's physician order dated 10/2/24 documents an order to increase haloperidol to 10 milligrams intramuscularly every eight hours as needed. As of 11/1/24, the order for the haloperidol was active for thirty days (10/2/24 to 11/1/24). R1's Medication Administration record for October of 2024 documents R1 received 10 milligrams of haloperidol on 10/13/24, 10/15/24, 10/17/24, 10/19/24, 10/20/24, and 10/24/24. R1's care plan with an initiation date of 8/30/24 does not include a plan of care for the use of psychotropic medications. This care plan does not include behavioral interventions. The facility's behavior tracking binder did not include a behavior tracking sheet for R1. R1's medical record did not include behavioral interventions or a behavior tracking sheet. On 11/2/24 at 9:17 AM, V2 Director of Nursing stated R1's haloperidol was ordered due to R1 having increased behaviors. V2 stated the medication order for the haloperidol did extend past 14 days. V2 confirmed R1's medical record nor the behavior tracking binder contained behavioral interventions for R1's behaviors. V2 confirmed that R1's care plan did not contain a plan of care for R1's use of haloperidol. 146080 Page 2 of 2