**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the psychiatrist's (medical practitioner specializing in the diagnosis and treatment of mental illness) services were provided to residents who were receiving psychotropic (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication for four out of six sampled residents (Residents 2, 17, 19, and 51). Resident 2 had a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Residents 17, 19, and 51 had diagnoses of dementia (a progressive state of decline in mental abilities), The facility failed to: 1. Ensure Residents 2, 17, 19, and 51, who were being treated with psychotropic medications including Cymbalta (a drug used to treat depression), Ativan (drug that is used to treat anxiety [feeling of fear, dread, and uneasiness]), Seroquel an antipsychotic (a class of drugs used to treat symptoms of psychosis [ a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), Depakote (a medication used to treat manic episodes - emotional highs- associated with bipolar disorder [bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]), Mirtazapine (medication to treat depression), Haloperidol (a high potency drug used to treat certain mental and neurological disorders), and Donepezil (a medication that treats symptoms of dementia like memory loss and confusion), were evaluated by a psychiatrist for the appropriateness of psychotropic medication use before starting the psychotropic medication regimen during use of psychotropic medications, and as needed. 2. Ensure Residents 2's medication regimen therapy with Cymbalta 30 milligrams ([mg] a unit of weigh measurement), that started on 4/23/2024, twice a day for depression, was evaluated by a psychiatrist to assess for appropriateness, effectiveness, and the need to increase or decrease medication dosage to ensure the resident's safety, and that Resident 2 reached the highest practicable quality of life. Resident 2 was admitted on [DATE] and has been taking psychotropic medications since admission. Resident 2 had not been evaluated by a psychiatrist since 2/28/2023. 3. Ensure Resident 17's psychotropic medication regimen was evaluated by a psychiatrist to assess the effectiveness of the psychotropic medications and the need to increase or decrease the dosage to ensure Resident 17 reached the highest practicable quality of life. Resident 17's medication regimen included: a. a. Cymbalta, 30 mg which Resident 17 started taking once a day, on 11/1/2024. b. Ativan 0.5 mg, which Resident 17 started taking twice a day on 9/14/2022. c. Seroquel 50 mg, which Resident 17 started taking every 12 hours on 6/2/2023 for bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and d. Depakote 250 mg, which Resident 17 started taking twice a day on 11/2/2024, 250 mg. 4. Ensure Resident 19's medication regimen therapy was evaluated by a psychiatrist to assess the effectiveness of the psychotropic medications and the need to increase or decrease the dosage to ensure Resident 19 reached the highest practicable quality of life. Resident 19 was admitted on [DATE] and has not been evaluated by a psychiatrist for being on psychotropics since admission. Resident 19's medication regimen included: a. Ativan 0.5 mg, which Resident 19 started taking every 12 hours on 5/14/2024. b. Mirtazapine 7.5 mg, which Resident 19 started taking every night starting on 10/17/2023. c. Seroquel 25 mg, which Resident 19 started taking every day on 12/14/2023, for dementia with agitation. 5. Ensure Resident 51's medication regimen therapy was assessed by a psychiatrist for effectiveness and the need to increase or decrease dosage so Resident 51 reached the highest practicable quality of life. Resident 51 was admitted on psychotropics since 12/19/2023 and has not been evaluated by a psychiatrist. A psychiatrist consult had been ordered on 7/23/2024 but as of 11/14/2024 Resident 51 have not been evaluated by a psychiatrist. Resident 51's was taking the following medication regimen included: a. Haloperidol 5 mg, which Resident 51 started taking every 12 hours on 10/2/2024, every 12 hours for psychosis. b. Seroquel 50 mg, which Resident 51 started taking twice a day, on 7/17/2024. c. Donepezil 5 mg which Resident 51started taking daily on 12/19/2023. 6. Ensure a psychiatrist was part of the Interdisciplinary team ([IDT] a resident's healthcare team consisting of various specialties who work together to provide care for a patient) meetings to evaluate the residents' behavior and use of psychotropic medication, and plan the care accordingly for Residents 2, 17, 19, and 51 regarding the need and appropriateness of a gradual dose reduction ([GDR] - the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) of psychotropic medications. 7. Ensure staff followed the facility's policy and procedure (P/P) titled, Dementia Care Manual indicating residents who have reoccurring behavioral disturbances should be routinely seen and reevaluated by a psychiatrist. 8. Ensure staff followed the facility's P/P titled, Antipsychotic Medication Use indicating antipsychotic medication will be prescribed at the lowest possible dosage for a short period of time and are subject to GDR and re-review. Residents will only receive antipsychotics medications when necessary to treat specific conditions for which they are indicated and effective. 9. Ensure staff followed the facility's P/P titled, Behavioral Assessment, Intervention and Monitoring dated 12/2016, that indicated the facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. 10. Ensure staff implemented the Facility Assessment (a review of the facility's needed resources and capabilities to provide care for its residents), reviewed 10/16/2024, which indicated the facility resources needed to provide competent support and care for the resident population every day and during emergencies- under Therapy services - Psychology Services and Behavioral Health Services as indicated. These deficient practices placed Residents 2, 17, 19, and 51 at high risk for receiving unnecessary psychotropic medication, experiencing the potential side effects associated with the use of these medications, and not to have behavioral symptoms under control. The potential side effect of psychotropic medications included but are not limited to the following: a. Ativan: drowsiness and confusion. b. Haloperidol: difficulty speaking/swallowing, loss of balance, muscle spasms, and extrapyramidal symptoms (EPS - motor problems that include Parkinsonian-like symptoms (stiffness, tremor, shuffling gait), acute dystonia (abrupt spasms of head and neck), and akathisia (physical restlessness). c. Seroquel: increased mortality (death) in elderly patients with dementia, chills, confusion, and dizziness. d. Depakote: confusion, crying, delusions (altered reality that is persistently held despite evidence or agreement to the contrary) of persecution, mistrust, and combativeness. e. Cymbalta: body aches, cough, constipation (bowel dysfunction that makes it difficult or infrequent to have a bowel movement), and dry mouth. f. Donepezil: diarrhea, loss of appetite, and trouble sleeping. g. Mirtazapine: dizziness and drowsiness On 11/14/2024 at 1:16 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause, serious injury, harm impairment or death to a resident) situation due to the facility's failure to obtain psychiatric services for Residents 2, 17, 19, and 51 was called in the presence of Administrator (ADM) and the Director of Nursing (DON). On 11/16/2024 at 6:48 p.m., the IJ was removed in the presence of the DON after the facility submitted an acceptable IJ Removal Plan ([IJRP] - interventions to correct the immediacy of the deficient practices) and the IJRP implementation was verified through observation, interview, and record review. The IJRP included the following immediate actions: 1. Residents 2, 17, 19 and 51 will be evaluated on 11/18/2024, by a psychiatrist and to be completed by end of the day on 11/21/2024. Following these evaluations, ongoing monthly psychiatric services will take place for these residents. In addition, evaluations and routine psychiatric services will be completed for residents with psychiatric diagnosis upon admission, thereafter, and as needed by a Psychiatrist. The facility will have a monthly Behavioral Intervention Treatment meeting where we will discuss and review any residents on a psychotropic medication and any recommendations will be discussed at this meeting. Those who will attend the meeting will include the Licensed Psychiatrist and the Licensed Pharmacist. Any Resident with a behavioral change in condition (increased behaviors or new behavior) will be placed on a 72-hour change of condition monitoring using the facilities matrix (a grid-like tool used to organize and analyze data about a healthcare facility) event titled Behavior Log. 2. On 11/14/2024 all licensed nurses, which included the Interdisciplinary team (IDT) members, the DON, the Assistant Director of Nursing (ADON), the Associate Director of Social Services (ADSS) and the Minimum Data Set (MDS) coordinator, working on the 7-3 & 3-11 shifts were in-serviced immediately on psychiatric diagnosis and the need for a psychologist or psychiatrist consult for residents on psychotropic medication. The Director of Staff Development (DSD) will do another in-service tomorrow morning on 11/15/2024 for those that were not here today. The DSD has a list of those on leave, vacation or who were not able to attend and when they are back on schedule will set a date for an Inservice as well. 3. The facility will ensure they will be able to meet the needs of residents who are admitted with psychiatric or behavioral needs based off the recently updated Facility Assessment (a review of the facility's needed resources and capabilities to provide care for its residents) revised on 11/14/2024. 4. The facility added Psychiatric Services to the Facility Assessment as we have obtained a psychiatric services company to evaluate those with psychiatric diagnoses and to assess the effectiveness and the need to increase or decrease medication dosage to ensure resident's safety and symptoms are under control. If the facility is unable to meet the needs of any resident, the ADSS will initiate the discharge planning process. Currently there are no residents whose needs we cannot meet. 5. The facility will ensure that a Psychiatrist/Psychiatric Nurse Practitioner participates in the monthly Behavioral Intervention Treatment meeting for those residents receiving psychotropic medications. The Psychiatrist/Psychiatric Nurse Practitioner will make routine rounding visits to assess the effectiveness and the need to increase or decrease medication dosage to ensure resident's safety and symptoms are under control. On these rounding monthly Behavioral Intervention Treatment meetings the team (Administrator, DON, ADON, ADSS, MDS Coordinator, DSD, Licensed contracted Pharmacist, and the Board-Certified Psychiatric Nurse Practitioner) will meet to discuss any recommendations and carry out any recommendations from those visits. 6. The facility's DON will monitor the current number of residents on psychotropic medications to ensure that every resident with psychotropic medications is receiving psychiatric services monthly. The Associate Director of Social Services/SSD will report the number of residents and visits to the facilities Quality Assurance Performance Improvement quarterly monitoring meetings with a threshold of 100% through November 2025. Findings: 1. During a review of Resident 17's admission Record, the admission Record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including dementia with other behavioral disturbance, bipolar disorder generalized anxiety disorder (mental health condition that causes people to experience excessive and uncontrollable worry about everyday events or activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), abnormalities of gait and mobility. During a review of Resident 17's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/3/2024, the MDS indicated Resident 17's cognition (the mental process of thinking, understanding, and processing information) was severely impaired. The MDS indicated the resident was independent when eating, needed set up assist with oral hygiene, needed moderate assist (helper does less than half the effort) with personal hygiene, needed maximal assistance (helper does more than half the effort) with showering, and was dependent on staff with toileting hygiene. The MDS indicated the resident was on antipsychotic medications since admission. The MDS also indicated a GDR had not been attempted and the physician had not documented a GDR was clinically contraindicated (a reason for a person to not receive a particular treatment or procedure because it may be harmful). During a review of Resident 17's Physician's Order Report dated 11/1/2024 - 11/10/2024, the Physician's Order Report indicated the following orders: a. Starting 6/27/2019, monitor for episodes of agitation that interfere with care, every shift, for use of Ativan. b. Starting 6/27/2019, monitor for restlessness that interfere with care, every shift, for use of Ativan. c. Starting 6/27/2019, monitor for side effects of anti-anxiety medication use Ativan. - Observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision (a loss of sharpness in your vision that makes it difficult to see fine details), skin rash. d. Starting 6/27/2019, monitor for side effects of antipsychotic medication use Seroquel - Edema (swelling caused by fluid building up in the body's tissues), postural hypotension (medical condition that causes a drop in blood pressure when you stand up or sit down), sweating, loss of appetite, urinary retention (a condition that makes it difficult to empty the bladder, either partially or completely). Special attention for tardive dyskinesia (a movement disorder caused by the long term use of antipsychotics that causes involuntary, jerky movements in the face and body), seizure disorder (chronic brain problem causing sudden burst of electric activity in the brain), chronic constipation (a common condition that involves infrequent or difficult bowel movements ), glaucoma (group of eye diseases that can damage the optic nerve, leading to vision loss and blindness), diabetes (group of diseases that result in too much sugar in the blood), skin pigmentation (refers to color of skin changing), jaundice (condition that causes the skin eyes, and mucous membranes to turn yellow or greenish)every shift. e. Starting 9/14/2022, Ativan. 0.5 mg twice a day, for anxiety manifested by restlessness or agitation that interferes with care, monitor for signs and symptoms of respiratory depression/sedation. f. Starting 10/7/2022, monitor behavior of being suspicious of everything that interferes with care, for Seroquel every shift. g. Starting 10/7/2022, monitor for behavior of easily getting irritated or getting angry that interferes with care, for Seroquel, every shift, h. Starting, 6/2/2023, Seroquel 50 mg oral, every 12 hours, for bipolar disorder, depressive type manifested by easily getting irritated or angry and suspicious at anything you say that interferes with care. i. Starting 7/23/2024, monitor for side effects of Anti-depressant Medication use (Cymbalta)- Observe resident closely for significant side effects: sedation (sleepiness caused by certain drugs), drowsiness, dry mouth, blurred vision, urinary retention, tachycardia (abnormally fast heartbeat), muscle tremor (an involuntary, rhythmic shaking of a body part) agitation, headache, skin rash, photosensitivity (skin becomes more sensitive to light and is more likely to burn), excessive weight gain. j. Starting 11/1/2024, Cymbalta capsule delayed release 30 mg, oral once a day. k. Starting 11/1/2024, Depakote delayed release tablet 250 mg, oral, twice a day, for bipolar disorder, depressive type manifested by easily getting irritated or getting angry and suspicious of anything you say, that interferes with care. l. Starting 11/1/2024, Monitor for side effects of Depakote observe resident closely for significant side effects: drowsiness, ataxia, nystagmus (condition that causes abnormal involuntary rhythmic eye movements), dizziness, blurred vision, nausea, rash, gum enlargement(a condition where the gums increase in size ), jaundice: Special attention in use with other Central Nervous System depressant drugs (drug that slows down the brain activity causing relaxation and calm) or if resident develops a fever (unhealthy increase in body temperature) blood dyscrasias (disorder of the blood). During an observation of Resident 17, on 11/8/2024 at 7:18 p.m., in Resident 17's room, Resident 17 was observed falling asleep while brushing her teeth. During an observation of Resident 17 on 11/9/2024 at 9:25 a.m., in the hallway in front of Resident 17's room, Resident 17 was observed sleeping in her wheelchair. During an interview and record review on 11/12/2024 at 9:15 a.m., with the ADON, Resident 17's Physician's Progress note, dated 11/1/2024 at 3:40 p.m., was reviewed. The Physician's Progress note indicated Resident 17's psychotropic medications were adjusted over the last several months due to Resident 17's complaint of feeling low in energy and drooling (saliva unintentionally flowing out of the mouth unintentionally). The Physician's Progress note indicated the psychotropic medications made it difficult for Resident 17 trust and think. The ADON stated primary physician 2 (MD 2), who is not a psychiatrist, managed Resident 17 psychotropic medications. The ADON stated Resident 17 was diagnosed with bipolar disorder and major depression, but the last psychiatric consultation Resident 17 had was on 11/29/2021. During an observation and interview on 11/12/2024 at 2:54 p.m., with Certified Nurse Assistant (CNA 3), by the door of Resident 17's room, Resident 17 was sleeping in her wheelchair. CNA 3 looked at Resident 17 and stated Resident 17 usually dozed off and falls asleep in her wheelchair, so the staff put her back in bed. During a phone interview on 11/13/2024 at 7:49 a.m., with the Licensed Pharmacist (LP), the LP stated that drooling or excessive salivation can be a side effect of psychotropic use. The LP stated psychotropic use was worse for elderly and even worse for dementia residents. The LP stated inappropriate psychotropic use can cause falls and can cause residents to be drowsy or sedated (falling asleep as a side effect of a drug). During an interview and record review on 11/13/2024 at 9 a.m., with the ADON, Resident 17's Behavior Quarterly Management Follow up, dated 7/3/2024, was reviewed. The ADON confirmed and stated Resident 17 was on Lorazepam 0.5 mg twice a day for anxiety manifested by episodes of restlessness or agitation that interferes with care. The Behavior Quarterly Management Follow up indicated for the month of January 2024, Resident 17 had zero episodes of restlessness and one episode of agitation. For the month of February 2024, Resident 17 had 4 episodes of restlessness and 3 episodes of agitation. For the months of March and April 2024 Resident 17 had no episodes of agitation and restlessness. The ADON stated Resident 17 was on Seroquel 50 mg every 12 hours for bipolar disorder, depressive type manifested by easily gets irritated or gets angry and suspicious of anything you say, that interferes with care. The ADON stated during the months of January, February and March 2024 Resident 17 had behaviors of easily getting irritated and paranoia, and in the month of April 2024 the resident had zero behaviors manifested. The ADON stated, Seroquel was increased last year to every 12 hours on 6/2/2023, the IDT team decided to continue the current psychotropic regimen because the benefits outweighed the risks for reduction. The ADON stated the physician was not contacted because the IDT team had decided there were no pharmacological (medication) adjustment required. The form indicated there was no physician signature indicating the physician or a psychiatrist was consulted with IDT decision to not complete the GDR and Resident 17 continue to receive the same medication at the same dose. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including major depressive disorder, spondylolysis lumbar region (age-related change of the back bones), and history of falling. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident was understandable and was able to understand others. The MDS indicated the resident was on setup or clean up assistance for eating and oral hygiene and dependent (helper does all the effort) on the staff for bathing, toileting hygiene, and transfer to and from the bed to a chair. During a record review of Resident 2's Physician's Order for Paroxetine (medication to treat depression), the order indicated Paroxetine was ordered for management of depression manifested by crying and verbalization of loneliness since admission 2/28/2023 and discontinued on 4/16/2024. During a review of Resident 2's Physician's Order Report dated 10/12/2024 - 11/12/2024, the Physician's Order Report indicated the following orders: a. Starting 4/23/2024, monitor episodes of crying every shift for Cymbalta. b. Starting 4/23/2024, monitor verbalizing loneliness every shift for Cymbalta. c. Staring 4/23/2024, Cymbalta delayed capsule release 30 mg oral for chronic musculoskeletal (having to do with muscles, bones, tendons, ligaments, joints, and cartilage) pain and depression manifested by crying and verbalizing loneliness. During an interview and record review on 11/12/2024 at 9:30 a.m., with the ADON, Resident 2's Copy of Behavior Quarterly Management Follow up, dated 7/3/2024 and timed at 5:56 p.m., was reviewed. The Copy of Behavior Quarterly Management Follow up indicated Paroxetine was discontinued and Cymbalta was added for both pain and management of depression manifested by crying and verbalization of loneliness. The ADON stated the Paroxetine had been ordered for Resident 2 upon admission to the facility on 2/28/2023 for major depressive disorder. The ADON stated Resident 2 has never been seen by a psychiatrist for management of Resident 2's psychiatric diagnosis of depression. The ADON stated Resident 2 has never had a psychiatric consult while in the facility for depression and while being on psychotropic medication. During an interview on 11/12/2024 at 2:35 p.m., with the ADSS, the ADSS stated the need for a medication dose adjustment was decided by the IDT team consist of the DON, the ADON, MDS coordinator, the Registered Dietician (RD), and the ADSS. After IDT makes determination, the physician then contacted to write the order. During an interview and record review on 11/13/2024 at 10:20 a.m., Resident 2's Behavior Quarterly Management Follow up, dated 9/20/2024 was reviewed and the ADON confirmed and stated the resident was doing well (not having behaviors) so the IDT team decided no pharmacologic changes in dose were needed for this quarter. The ADON stated the IDT team only called and notified the physician if the IDT team recommended a medication dose adjustment or need for more pharmacological measures. 3. During a review of Resident 19's admission record, the admission Record indicated Resident 19 was admitted on [DATE] with diagnoses including dementia with agitation. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognition was severely impaired. The MDS indicated Resident 19 was dependent on facility staff to complete activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated the resident was routinely on antipsychotic medications since admission. Resident 19 was on During a review of Resident 19's Physician's Order Report dated 10/11/2024 - 11/11/2024, the Physician's Order report indicated. a. Starting 10/17/2023, monitor combativeness every shift for Seroquel. b. Starting 10/17/2023, monitor for continuous screaming that interferes with care every shift for Seroquel. c. Starting 10/17/2023, monitor for side effects of antipsychotic medication use (Seroquel) - Observe closely for significant side effects: Common - sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, and urinary retention. Special attention for tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, jaundice every shift. d. Starting 10/17/2023, Mirtazapine 7.5 mg at bedtime for depression. e. Starting 12/14/2023, Seroquel 25 mg, oral, once a day, for dementia moderate agitation manifested by combativeness and continuous screaming that interferes with care. Increased mortality in elderly patients. f. Starting 5/14/2024, Ativan 0.5 mg oral, for anxiety manifested by inability to express what she wants and ending up yelling out and crying, every 12 hours. g. Starting 5/15/2024, monitor for unable to express what she wants and end up yelling out and cry, every shift, for Ativan. h. Starting 5/14/2024, monitor for side effects every shift of anti-anxiety medication use Ativan - Observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash: special attention if given with other sedatives hypnotics (a prescription medication that slows brain activity to calm a person down, relieve anxiety, or help them sleep), or alcohol. During an interview and record review on 11/12/2024 at 1:39 p.m., with the ADON, Resident 19's View Safety Alert Acknowledgement for Seroquel was reviewed. The View Safety Alert Acknowledgement Alert indicated a Black Box warning (the most serious warning that the U.S. Food and Drug Administration - [FDA] - can issue for a medication used to inform health care providers and consumers about serious adverse reactions or risks associated with a drug) indicating Seroquel should be used with extreme caution with patients with senile dementia (diseases related old age) The ADON stated Resident 19 was admitted to the facility with a diagnosis of dementia with agitation and Resident 19 had been on Seroquel. The ADON stated she overrode the Acknowledgement, and she did not select a reason for the override of the Alert. The order for Seroquel, dated 12/14/2023, was also reviewed and the warning of the View Safety Alert indicated an increased mortality in elderly residents. The ADON stated the Black Box warnings and Safety Alerts on medications were supposed to be reviewed because the Alerts indicated that there was increased risk for harm for the residents taking the medication mentioned in the Alert. During an interview and record review on 11/12/2024 at 1:39 p.m., with the ADON, Resident 19's Behavior Quarterly Management Follow Up, dated 10/31/2024 and timed at 7:51 a.m., was reviewed. The Behavior Quarterly Management Follow Up indicated Seroquel was increased on 12/14/2023, Ativan was changed from PRN (given as needed or requested) to being administerd every 12 hours on 5/14/2024, and Mirtazapine was continued. The ADON stated Resident 19 was on three psychotropics concurrently and Resident 19 had never had an assessment by a psychiatrist to evaluate the need for psychotropic medication since she has been in the facility. 4. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnoses including dementia with psychotic (set of symptoms that indicate a loss of touch of reality) disturbance, and anxiety disorder. During a review of Resident 51's MDS, dated [DATE], the MDS indicated the resident's cognition was severely impaired. The MDS indicated Resident 51 was dependent on staff with bathing, toileting hygiene, dressing, personal hygiene, oral hygiene, and transfer to and from the bed to a chair. The MDS indicated Resident 51 was routinely on antipsychotic medications since admission. The MDS also indicated a GDR had not been attempted. During a review of Resident 51's Physician's order Report (active orders) dated 10/12/2024 - 11/12/2024, the Physician's order Report indicated the following orders: a. Starting on 12/19/2023, Donepezil (medication to treat dementia), oral, 5 mg, once a day. b. Starting on 7/11/2024, monitor for behavior of continuous yelling out that interferes with care every shift. c. Starting on 7/11/2024, monitor behavior of resisting care every shift. d. Starting on 7/17/2024, Seroquel 50 mg, oral, twice a day for dementia with agitation. e. Starting on 7/20/2024, Ativan 0.5 milligrams oral, every 12 hours as needed for anxiety manifested by constantly yelling that interfere with self and other residents. The order was discontinued on 9/23/2024. During review of physician's order dated 7/23/2024, the order indicated a psychiatric consult for Resident 51. During a review of Resident 51's Progress Notes, the Progress Notes indicated the following: a. On 7/23/2024 at 12:46 p.m., order received for psychiatric consultation due to continuous yelling out. b. On 7/29/2024 at 11:12 a.m., Resident 51 continued the constant disruptive yelling for 18-20 hours a day, causing multiple other residents (unidentified) to have agitative disruptive behaviors as well. Resident 51 was yelling so much Resident 51 would not eat, or drink fluids and this distressing behavior was attributing to her continued weight loss. Resident 51 was inconsolable and not redirectable. c. On 7/29/2024 the Progress Notes indicated a new order from MD 1 for Haloperidol 2.5 mg oral every 12 hours. During a review of Resident 51's physician's order dated 7/29/2024 at 11:09 a.m., the order indicated Haloperidol 2.5 mg oral every 12 hours for dementia with psychosis and agitation manifested by resisting care and continuous yelling out interferes with care and safety. During a review of Resident 51's Physician's order Report dated 10/12/2024 - 11/12/2024, the report indicated, starting 7/29/2024, monitor the resident for side effects every shift for anti-psychotic use (Seroquel and Haloperidol) - Observe closely for significant side effects: Common - sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention. Special attention for tardive dyskinesia, seizure disorder, chronic constipation, glaucoma, diabetes, skin pigmentation, jaundice. During a review of Resident 51's physician's order dated on 9/23/2024 and timed at 9:39 p.m., the order indicated Ativan 0.5 mg, every 12 hours as needed for anxiety manifested by constantly yelling that interfere with self and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedures (P&P) titled, Scabies Identification, Treatment and Environmental Cleaning, and Infection Control Program, for five of 23 residents (Residents 5, 18, 19, 21, and 31) who had a suspicious skin rashes ( the skin that has changes in texture or color and may be inflamed or irritated) by failing to: 1.Ensure Residents 5, 18, 19, 21 and 21, who had red scattered inflamed red spots with bumps and itching, were placed on isolation (separation of residents with an infection from residents without an infection). 2.Initiate and conduct infection surveillance (close observation or monitoring) by completing a line listing (a table that contains key information about each case in an outbreak) of residents with a suspicious rash in the Dementia (a progressive state of decline in mental abilities) Unit (a secure environment that provides specialized care for people with dementia). 3.Ensure precautionary measures were implemented to ensure suspicious rashes were contained for Residents, 5, 18, 19, 21, 31 and other residents in the secured unit 4.Coordinate with the local Department of Public Health to obtain guidance on how to handle the suspicious rashes. These deficient practices had the potential to spread a suspicious rash infection to all residents, staff, vendors, and visitors of the facility. On 11/10/2024 at 8:11 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called in the presence of the facility's Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to establish and maintain an for five residents (Resident 19, 31, 5, 18, and 21) with suspicious skin rashes. The facility had 23 total residents in the dementia unit. On 11/11/2024 the facility submitted an acceptable IJ Removal Plan ([IJRP] interventions to immediately correct the deficient practices). After onsite verification of the facility's IJRP's implementation through observation, interview, and record review, the IJ was removed on 11/11/2024 at 5:56 p.m., in the presence of the facility's DON and ADM. The facility's IJRP included the following immediate actions: 1. The facility conducted body skin assessments on the five residents listed on the IJ document. Resident 19, Resident 5, Resident 18, and resident 31 had rashes. Resident 21 did not have rashes but had scratches on her skin. All five residents were placed on contact isolation (precautions intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the person or the person's environment) with no stop date as of now. Additionally, the facility conducted body skin assessments on the remaining 18 residents in the Covenant Care Unit- the dementia unit referenced in the IJ document the facility was provided (CCU), no rashes were found on the remaining 18 residents. A line list was created for all 23 CCU residents. The facility also created a CCU Line List for Skin Rashes for staff that work in CCU. The facility staff were contacted, or messages were left for those staff assigned in CCU, to inquire if they had any rashes. 25 staff were called and 16 said they have no rashes. The facility staff will follow up with the other staff in the morning on 11/11/2024. On 11/11/2024 facility staff followed up with the remaining staff and they reported no rashes. All 25 CCU staff denied having rashes. 2a. On 11/10/2024 at 8:51p.m., the facility notified the Medical Director (MD 1) of all the interventions that are being implemented. MD 1 agreed to the dermatologist consult order for Resident 21, who did not have rashes but had scratches on her skin. 2b. The facility notified the Primary Care Physician (PCP) 1 on 11/10/2024 at 9:10 p.m., of this said IJ. PCP 1 is the Physician for 3 of the residents (Residents 5, 18 and 31). PCP 1 did order dermatology consults for the 3 residents. PCP 1 also gave a new order for Hydroxyzine (medication that treats the symptoms of allergies and allergic reactions) as needed for Resident 18. 2c. PCP 2 was notified on 11/10/2024 at 9:20 p.m., of this said IJ. PCP 2 is the physician for resident 19. PCO 2 ordered a dermatology consult for Resident 19. 2d. On 11/11/2024, The Director of Social Services Department (DSSD) was able to schedule the dermatology appointments for the 5 residents (Residents 19, 5, 18, 21, 2 3) whose families agreed to dermatology consults. Two residents will go to the dermatology appointment on Tuesday 11/12/2024 (Residents 19 and 31). The other three residents will go to their dermatology appointments on Thursday 11/14/2024 (Residents 5, 18, and 21). 3. The facility also notified the CDPH (non-licensing division) on 11/10/2024 at 10 p.m. The DON spoke to county operator #10. Then operator #10 transferred DON to the on-call MD. The DON spoke to the on-call MD from 10:01 p.m. to 10:15 p.m. The DON reported the IJ and the current skin issues for said residents. The DON also reported all interventions the facility has done and implemented. The on-call MD said the case will be referred to the local regional Public Health Nursing (PHN) team and the PHN team will connect with the facility. 4. On 11/10/2024 all Licensed Nurses and Certified Nursing Assistants (CNAs) working on the 3 p.m.-11 p.m. shift were in serviced immediately on skin issues, infection control, use of PPE (personal protective equipment refers to protective clothing, gloves and facemasks or other equipment designed to protect the wearers from injury or the spread of infection or illness) and isolation precautions (precautions used to reduce transmission of microorganisms in healthcare). Upon arrival today, 11/10/2024, the 11 a.m.- 7 p.m., shift licensed nurses and CNAs were also in-serviced on the same topics. The Director of Staff Development (DSD) would complete another in-service on 11/11/2024 for those staff that were not in the facility today. On Monday 11/11/2024 the DSD did an in-service again for those staff who were not at the facility yesterday (11/10/2024). The DSD has a list of those on leave, vacation or who were not able to attend and when they are back on schedule will set a date for an in-service as well. The facility also implemented the precautionary measures listed in paragraph 1, 2 and 3. 5. The facilities Infection Preventionist (IP) or designee would monitor and track any residents with suspicious rashes and maintain an infection control program by ensuring they are added to line listings for surveillance purposes, placed on isolation, ensure precautionary measures were done and implemented and reach out to DPH when facility staff suspect an outbreak has occurred for additional guidance on how to handle the situation. A root cause analysis would be done for those residents with suspicious rashes. The facilities IP or designee would report the findings to the facilities quarterly QAPI (Quality Assurance and Performance Improvement- a data driven proactive approach to improvement used to ensure services are meeting quality standards) monitoring meeting with a threshold of 100% compliance through November 2025 for all current and future residents have the potential to be affected by this deficient practice. Findings: 1a. During a review of Resident 5's admission Record (AR), the AR indicated Resident 5 was admitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities). During a review of Resident 5's Minimum Data Set (MDS, a resident assessment tool) dated 10/3/2024, the MDS indicated Resident 5's cognition (ability to process and understand information) was severely impaired. The MDS indicated Resident 5 was dependent (helper does all the effort) on facility staff to complete activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 5's Progress Notes dated 10/25/2024, the Progress Notes indicated Resident 5's physician was notified regarding Resident 5's generalized rashes which appeared like red lesions (an area of abnormal or damaged tissue caused by injury, infection, or disease) with bumps, dry and rough in texture, and occasionally itching by Resident 5. The Progress Note indicated Resident 5's physician ordered permethrin cream (medication used to treat scabies, a condition caused by tiny insects called mites that infest and irritate the skin) 5% to treat the rashes. During a review of Resident 5's Physician Order (PO), dated 10/25/2024, the PO indicated permethrin 5% to be applied to Resident 5's body from the neck to sole of the feet overnight for 8 hours and wash off in the morning for generalized rashes once a day on Friday for 2 weeks. During a review of Resident 5's Treatment Administration Record (TAR) for 10/2024 and 11/2024, the TAR indicated permethrin cream 5% was administered/applied to Resident 5 on 10/25/2024 and 11/1/2024. 1b. During a review of Resident 18's AR, the AR indicated Resident 18 was admitted on [DATE] with hospice care (a comprehensive, holistic program of care and support for terminally ill patients and their families) and diagnoses including dementia. During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18's cognition was severely impaired. The MDS indicated Resident 18 was dependent on facility staff to complete ADLs. During a review of Resident 18's POs, dated from 10/24/2024 to 11/7/2024, the POs indicated: On 10/24/2024, an order for scattered rashes on upper back: cleanse with soap and water, pat dry and apply hydrocortisone cream (cream to reduce swelling, itchiness, and redness in skin conditions) 1 percent (%), twice a day for 14 days. On 11/7/2024, an order for scattered rashes on the chest: cleanse with soap and water, pat dry and apply hydrocortisone cream 1%, twice a day for 14 days. On 11/7/2024, an order for scattered rashes on upper back: cleanse with soap and water, pat dry and apply hydrocortisone cream 1%, twice a day for 14 days. During a review of Resident 18's Progress Notes (PN), dated 10/24/2024, the PN indicated Resident 18 was experiencing scattered rashes on the chest and upper back which appeared to be red spots with bumps and appeared inflamed (red, sore, and often swollen). The PN indicated PCP 1 ordered hydrocortisone cream 1%, twice a day for a duration of 14 days. During a review of Resident 18's PN, dated 11/7/2024, the PN indicated a new order was received from the Hospice Nurse (HN) to continue to cleanse the rashes on the upper back and chest with soap and water, pat dry and apply hydrocortisone cream 1% for a duration of 14 days. During a review of Resident 18's untitled Care Plan (CP), dated 10/24/2024 related to Resident 18's rashes on the chest and upper back, the CP indicated a goal for the rashes to heal without complication. The CP interventions indicated treating the rashes per physician's order. During a review of Resident 18's Medication Administration Records (MARs) dated 10/2024 and 11/2024, the MARs indicated that 10/24/2024 -11/10/2024, Resident 18 received hydrocortisone cream 1% to the scattered rashes on the chest and upper back. 1c. During a review of Resident 19's AR, the AR indicated the facility admitted Resident 19 on 10/16/2023 with diagnoses including dementia. During a review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19's cognition was severely impaired. The MDS indicated Resident 19 was dependent on facility staff to complete ADLs. During a review of Resident 19's POs, dated 10/12/2024, the POs indicated: An order for a dermatology consult for generalized rashes. An order for Permethrin cream 5 % apply to whole body with special instructions to apply from the neck down to sole of the feet overnight for 8 hours and wash off in morning for generalized rashes, once a week on Tuesday for 2 weeks. During a review of Resident 19's PN, dated 10/22/2024 at 4:19 p.m., the PN indicated an order from PCP 1 to obtain a dermatologist consult when available for generalized rashes. During a review of Resident 19's PN, dated 10/22/2024 at 4:55 p.m., the PN indicated PCP 1 was contacted to inform PCP 1 of Resident 19's rashes starting in the mid chest, spreading to the left upper arm, posterior back, right upper chest, left hip, and right posterior thigh. The PN indicated the rashes appeared as small, scattered scabs (the crusty patch of skin that forms when a scrape or cut is healing) with reddened surrounding areas. The PN indicated Resident 19 was reporting occasional itching, and PCP 1 ordered Permethrin cream 5%. During a review of Resident 19's untitled CP, dated 10/4/2024, the CP indicated Resident 19 experienced rashes on the mid chest and left upper arm. The CP indicated a goal for Resident 19's rashes to heal without complication with the interventions of discouraging resident from scratching and treating the rashes per physician's order. During a review of Resident 19's MAR for 10/2024, the MAR indicated Resident 19 received a dose of Permethrin cream 5%, applied to the whole body on 10/22/2024. 1e. During a review of Resident 21's AR, the AR indicated Resident 21 was admitted on [DATE] with diagnoses including dementia. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21's cognition was moderately impaired. The MDS indicated Resident 21 was dependent on facility staff to complete ADLs. During a review of Resident 21's PO, dated 11/6/2024, the PO indicated for the scattered rashes on the chest: cleanse with soap and water, pat dry and apply a thin layer of hydrocortisone cream 1% and leave open to air twice a day for a duration of 14 days. During a review of Resident 21's Skin Integrity Events- Rash/Lesions document, dated 11/6/2024, the Skin Integrity Events- Rash/Lesions document indicated Resident 21 had scattered redness on the chest. During a review of Resident 21's TAR for 11/2024, the TAR indicated from 11/6/2024 through 11/9/2024, Resident 21 had scattered rashes to the chest which were cleansed with soap and water, patted dry and a thin layer of hydrocortisone cream 1% was applied. 1f. During a review of Resident 31's AR, the AR indicated Resident 31 was admitted on [DATE] with diagnoses including dementia. During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31's cognition was severely impaired. The MDS indicated Resident 31 was dependent on facility staff to complete ADLs. During a review of Resident 31's PO, dated 10/1/2024, the PO indicated an order for the scattered rashes on abdomen: cleanse with soap and water, pat dry, and apply Hydrocortisone cream 1 %, twice a day for a duration of 14 days. During a review of Resident 31's PN, dated 11/8/2024, the PN indicated Resident 31 was experiencing rashes that spread throughout the chest and hip. The PN indicated the rashes appeared pink and raised, and mild itchiness was observed. The PN indicated PCP 1 was notified and PCP 1 ordered to continue the current treatment of hydrocortisone cream. During a review of Resident 31's PN, dated 11/8/2024, the PO indicated an order for generalized rashes: cleanse with soap and water, pat dry, and apply Hydrocortisone cream 1% twice a day for a duration of 14 days. During a review of Resident 31's untitled CP, dated 11/1/2024, the CP indicated Resident 31 experienced scattered rashes on Resident 31's abdomen. The CP indicated a goal for the scattered rashes healing without complication. The CP interventions included a dermatology consult. During a review of Resident 31's TAR for 11/2024, the TAR indicated Resident 31 received hydrocortisone cream 1% twice a day for scattered rashes on the abdomen from 11/1/2024 -11/10/2024. During a review of the facility's Housekeeping Checklist for 11/2024, the SNF Housekeeping Checklist indicated privacy curtains were changed every quarter (January, April, July, and October) beds, closets, lamps, and furniture are cleaned every month. During an interview on 11/9/2024 at 1:05 p.m., with the Housekeeper (HK), the HK stated she has not performed any deep cleaning (a thorough cleaning that eliminates visible dirt, bacteria, and germs; is a lot more extensive than standard weekly cleaning) of any room recently in the dementia care unit. During an interview on 11/10/2024 at 6:32 a.m., with Treatment nurse (TN 1), TN 1 stated that Resident 18 was scratching and has rashes. TN 1 stated Resident 18's rash has not improved while being treated by hydrocortisone cream for 14 days starting on 10/25/2024 so the PCP 1re-ordered the hydrocortisone for another 14 days starting on 11/7/2024. During an interview on 11/10/2024 at 6:41 a.m., with Certified Nursing Assistant 1 (CNA1) regarding the rashes on Residents 18, 19 and 21, CNA 1 stated Resident 18 has a rash around Resident 18's neck, Resident 19 scratches around Resident 19's upper chest and has rashes, and Resident 21 scratches on Resident 21's upper chest and has rashes. During an interview on 11/10/2024 at 6:59 a.m., with Licensed Vocational Nurse 1 (LVN 1) regarding Resident 5, 18, 19 and 21's rashes, LVN 1 stated she has seen Resident 18 scratching Resident 18's neck; Resident 5 has a generalized rashes on Resident 19's body, Resident 19 has redness and rashes on her chest and is scratching around her upper chest; and Resident 21 has redness and scratches on Resident 21'schest area. During an interview on 11/10/2024 at 9:15 a.m., and 3:32 p.m., with the Assistant Director of Nursing (ADON), the ADON stated Residents 5 and 9 were ordered permethrin cream to treat rashes prophylactically (to prevent or protect against disease or infection). The DON stated there was no skin scraping (a common procedure used to obtain the superficial dead layers of the skin used to diagnose skin infections) ordered. The DON stated the residents (Resident 5 and 9) were placed in isolation when the cream was applied (duration of 8 hours), and the residents' clothing was sent to the laundry. The ADON stated no precautionary measures, to prevent the spread of the rashes were done for the roommates of Resident 5 and 19. The ADON stated there were a total of five residents who are experiencing rashes. The ADON stated there was no line listing for skin surveillance after Residents 5 and 19 were treated with permethrin cream for other residents and staff. The ADON stated in the past, the facility had experienced residents with suspicious rashes, then they administered the permethrin cream, deep cleaned the rooms, provided precautionary measures such as contact isolation for the residents, and did skin surveillance for other residents and staff at risk. During an interview on 11/10/2024 at 6:33 p.m., with the DON, the DON stated she was aware Residents 5 and 9 were treated with permethrin for generalized rashes. The DON stated Residents 5 and 9 were treated with permethrin as an off label use (used for a disease or medical condition that the medication is not approved to treat) for generalized rashes. The DON stated Resident 5 had not been assessed by dermatology for the rashes. The DON stated Resident 9 was awaiting authorization for a dermatology consult. The DON stated she was aware other residents (Residents 31, 18 and 21) were experiencing rashes, but she was unsure if a line listing for skin surveillance for residents and staff was completed. The DON stated the suspicious rashes was not reported to the Department of Public Health. The DON stated the housekeeping staff have their daily, weekly, monthly, and quarterly cleaning routines and have not completed a deep clean in the secured unit to prevent the rashes from spreading. During an interview on 11/13/2024 at 7:49 a.m., with the Facility Pharmacy Consultant (PC), the PC stated permethrin can be prescribed for prophylaxis but there is no indication it can be used off-label to treat generalized rashes. During a review of the facility's P&P) titled, Scabies Identification, Treatment and Environmental Cleaning, dated 8/2016, the P&P indicated when scabies is treated with Permethrin cream, the resident should be placed on contact precautions during treatment period and 24 hours after application of permethrin cream. The P&P indicated the resident's bed linens, towels, and clothing used during the four days prior to initiation of treatment should be placed in plastic bags inside the resident's room, handled by gloved and gowned staff without sorting, and washed in hot water for 10-20 minutes. During a review of the facility undated P&P titled, Infection Control Program, the P&P indicated the facility residents would be provided screening for infectious diseases, physical exams and health histories, infection monitoring and treatment for infectious disease. The P&P indicated surveillance (close observation) of residents would include maintenance of an infectious disease log and reporting individual incidents of infection documented in the log.