Health inspection·May 4, 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 provide informed consent for an antipsychotic medication, failed to identify target behaviors and failed to identify an appropriate supporting diagnosis for one resident (R22) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 15. Findings include: Facility Policy/Psychotropic Medication Policy dated 1/16/19 documents: Prior to the administration of a psychotropic medication, the following includes a process for the IDT (Interdisciplinary Team) and resident/resident representative to participate in the care process: The indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and identification of behavioral symptom(s) being treated. Antipsychotic Medication: Diagnoses alone do not necessarily warrant the use of an antipsychotic medication. Antipsychotic medications may be indicated 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 contraindicated, multiple non-pharmacological approaches have been attempted, but did not relieve the symptoms which present a danger or significant distress to the resident. If antipsychotic medications are prescribed, documentation must clearly show indication for the medication, multiple attempts to implement care-planned, non-pharmacological approaches and ongoing evaluation of the effectiveness of these interventions. A Psychotropic Drug Assessment will be completed on admission, quarterly, an irregularity identified in the pharmacist's medication regimen review and with significant changes of condition. Consent: Provide the resident/resident representative with information on the medication, indication, dose, side effects, adverse consequences and goal of treatment. The goals of psychotropic medication and non-pharmacologic approaches will be addressed in the resident's care plan. The care plan will also include the classification of psychotropic drug(s) to be monitored for side effects daily. On 5/2/23 and 5/3/23 R22 was observed sitting in his room and also sleeping/napping in bed after lunch. On 5/2/23 R22 was sitting in his room in a wheelchair. After being greeted, R22 began talking about people and events in a rambling but calm manner. R22 was able to answer simple questions, however, could not stay focused on topic and would continue to ramble. Psychotropic Medication Consent indicates Abilify 2mg daily was signed by R22's representative on 2/9/23 and consent signed on 3/13/23 indicates Abilify was increased to 3mg on that date. Neither (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146103 If continuation sheet Page 2 of 3 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 146103 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Henderson County Ret Center 604 Oakwood Drive Stronghurst, IL 61480 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 consent indicates a diagnosis, indication for use, specific side effects or target behaviors. Level of Harm - Minimal harm or potential for actual harm Current POS (Physician's Order Summary) indicates R22 has orders for Abilify (antipsychotic) 3mg (milligrams) daily related to Severe Unspecified Dementia with Mood Disturbance, Severe Recurrent Major Depressive Disorder with Psychotic Symptoms. Residents Affected - Few CNA (Certified Nurse Assistant) Behavior Monitoring indicates: February 2023 Rejection of care/twice; yelling/9 times; abusive language 6 times, March 2023 Rejection of care/once; yelling/10 times; abusive language twice; wandering/once, April 2023 Yelling/twice; abusive language/once and May 2023 No behaviors. R22's Current Care Plan indicates R22 has a behavior problem related to Dementia. R22 is alert with confusion; known to yell out at staff during cares and has been known to refuse care and medications. R22 can become verbally aggressive with staff during cares. R22 will often watch television and yell out at the television; will have conversations with himself at times. [NAME] has been known to have hallucinations/delusions with paranoid behaviors. R22's Care Plan also indicates (R22) uses psychotropic medications related to Major Depressive Disorder with psychotic features. R22's Care Plan does not identify what type/category of psychotropic (antipsychotic) R22 receives or target behaviors. Progress Note dated 4/5/23 at 4:47am indicates R22 usually sleeps well and engages in confused conversation at times. Progress Note dated 4/13/23 at 11:41am indicates R22 was alone in his room after breakfast, staff overheard R22 talking and swearing at (someone) however no one else was in the room. Note indicates behavior was discussed with spouse who stated, I just don't think that medicine is doing him a bit of good anymore. Physician Note dated 3/13/23 indicates R22 has diagnosis of Dementia without behavioral disturbance and behavior is cooperative. Note indicates to Avoid medications on Beer's List. (The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, commonly called the Beer's List, are guidelines published by the American Geriatrics Society (AGS) for healthcare professionals to help improve the safety of prescribing medications for adults 65 years and older. The Beer's List includes the antipsychotic Abilify). Psychotropic Medication Consent indicates Abilify 2mg daily was signed by R22's representative on 2/9/23. Consent does not indicate an indication for use, diagnosis, side effects or target behaviors. On 5/3/23 at 3:10pm V2, DON (Director of Nursing) stated prior to starting the Abilify, R22 was having multiple episodes per day of yelling at the TV, yelling at self and seemed distressed. V2 stated that R22 was referred to Behavioral Health Services and they recommended to start R22 on Abilify. V2 stated the Behavioral Health practitioner told her There was all this evidence that Abilify is not even an antipsychotic until it reaches a certain dosage. V2 stated we did increase the dosage once and (R22's) wife wanted us to increase it more because she believed it was helping although his behaviors did return. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146103 If continuation sheet Page 3 of 3