**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent falls for one of four sampled residents (Resident 1) when Resident 1 was assessed as being at high risk had poor safety awareness (not paying attention to the dangers around you, a history of self-transferring to get to the bathroom, frequent urination (act of releasing liquid waste that your kidneys make to remove excess fluids and waste products from your body) and needed to be supervised by a staff member during transfer and the facility did not implement individualized interventions to prevent falls, including supervision and addressing the cause of frequent self-transferring attempts, consistent with the resident's needs, goals and care according to the resident assessment and plan of care.These failures resulted in Resident 1 sustaining four unwitnessed falls, two falls on 5/19/25, one fall on 6/16/25 and one fall on 7/16/25. During the fall on 7/16/25, Resident 1 sustained an intertrochanteric fracture (a type of hip fracture [broken bone] where the femur [upper thigh bone] meets the pelvis [ring of bones in the hips and lower back that connects the upper body to the legs]) causing her significant pain, decreased mobility and the resident became bedbound (unable to leave the bed). Resident 1 was not transferred to the emergency department because she was on hospice [specialized form of for end-of-life care] and the Responsible Party's request.During a review of Resident 1's admission Record, undated, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture of superior rim (upper edge) of right pubis (pubic bone-a bone that makes up the pelvis), displaced intertrochanteric fracture of left femur, dementia (decline in mental ability severe enough to interfere with daily life), retention of urine (inability to completely empty the bladder), and anxiety disorder (feeling of unease, worry or fear).During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE] , it indicated Resident 1's Brief Interview of Mental Status assessment (BIMS-assessment of cognitive status for memory and judgement) scored 05 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment score indicated Resident 1 had severe cognitive impairment.During an interview on 8/12/25 at 8:42 a.m. with the Administrator in Training (AIT), the AIT stated Resident 1 was no longer in the facility because she had passed away on hospice on 7/27/25.During an interview on 8/12/25 at 9:26 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated she was not at the facility when Resident 1 fell and fractured her hip on 7/16/25. CNA 1 stated Resident 1 was a high fall risk and had behaviors of frequently getting up and trying to self-transfer while unsupervised. CNA 1 stated Resident 1 was not safe to transfer without assistance. CNA 1 stated Resident 1 had frequent urgency (sudden, compelling need to urinate) to go to the restroom because she felt like she needed to urinate (pass urine from the body). CNA 1 stated the staff would take Resident 1 to the restroom, and she would ask to go again within minutes of urinating.During an interview on 8/12/25 at 10:27 a.m. with CNA 2, CNA 2 stated she took care of Resident 1 while she was in the facility. CNA 2 stated she would want to toilet all the time. We would take her to the bathroom often, then she would want to go again right away. CNA 2 stated even though staff frequently took Resident 1 to the bathroom, she would try to get up unassisted because she felt like she needed to go again, which increased her fall risk. During a concurrent interview and record review on 8/12/25 at 10:51 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was working when Resident 1 fell on 7/16/25. LVN 1 stated on 7/16/25 around 6:55 a.m., she had just arrived at the facility for her shift and saw Resident 1 in bed. LVN 1 stated she had walked to the nurse's station for report from the night shift and a CNA told her Resident 1 was on the floor. LVN 1 stated she assessed Resident 1 for injuries and Resident 1 complained of pain to her right leg from the back of her knee to her hip. LVN 1 stated Resident 1 appeared to be in pain, so she administered her pain medication . LVN 1 stated Resident 1 was able to move but complained of pain. LVN 1 stated Resident 1 was unable to bear weight on her right leg, so she called hospice and notified them Resident 1 had fallen. LVN 1 stated the hospice nurse came in around 7:30 a.m. for a routine visit and she asked the hospice nurse for an order to X-ray (a painless test that captures images of the structures inside the body) Resident 1's hip but was told to just keep the resident comfortable. LVN 1 stated she was informed by the hospice nurse that because hospice was for end-of-life care, they did not routinely perform X-rays on patients. LVN 1 stated Resident 1's pain continued to worsen, and she had facial grimacing [facial expression that show pain], so they requested an X-ray order from hospice a second time and received an order. Resident 1's X-ray report titled Right Hip, Unilateral [one side] W/ [with] Pelvis, dated 7/16/25 was reviewed, it indicated, . Acute intertrochanteric fracture with impaction [broken ends of a bone are driven into each other] and varus angulation [deviation of the bone towards midline of the body] . Soft tissue swelling [abnormal buildup of fluid] around the right hip. LVN 1 stated the Director of Nursing (DON) had contacted Resident 1's responsible party and they did not want the resident sent to the hospital and requested the resident be kept comfortable at the facility. LVN 1 stated Resident 1 had increased pain, and her morphine sulfate (a powerful pain medication) was changed from as needed to routine for pain control. LVN 1 stated Resident 1 had fallen before the 7/16/25 fall, twice on 5/19/25 and once on 6/16/25. Resident 1's care plan dated 7/16/25 indicated, . at risk for fall related to actual fall on 7/16/2025 . 72-hour alert monitoring . X-ray . Communicated X-ray findings to MD [physician]/hospice/IDT [interdisciplinary team-involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident] . Manage resident fall risk through facility red sneaker program . LVN 1 stated the Red Sneaker Program was the facility's fall prevention program and was used for all residents with high fall risk and was not specific to Resident 1. LVN 1 stated Resident 1 needed increased supervision because she had behaviors of getting up to transfer without assistance because she felt like she needed to use the restroom frequently. LVN 1 stated Resident 1 had the urge to urinate frequently causing her to try and transfer herself. LVN was unable to find interventions that addressed urinary frequency and attempts to self-transfer . Resident 1's Fall Risk Assessment, dated 7/3/25, was reviewed. The assessment indicated, . High Risk for Falls . LVN 1 stated Resident 1 fell because she did not have enough supervision and would have required one on one (direct, individualized supervision) to prevent her from falling. During a review of the facility's Red Sneaker Program, the program indicated, . Criteria for Inclusion in the Red Sneaker Program. Resident had had a fall in the last 90 days . has a Fall Risk Assessment Score of above 10 . Care Plan Implementation . Anticipate toileting needs of High Risk for Fall Residents . Focus on residents who are High Risk for Falls that may be attempting to ambulate independently . DON and IDT will make sure appropriate individualized CPs [care plans] and interventions are in place .During a concurrent interview and record review on 8/12/25 at 11:33 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS Section GG [functional status], dated 7/3/25 was reviewed and indicated, . sit to stand [code 02-substantial/maximal assistance- helper does more than half the effort] . Chair/bed-to-chair transfer [code 02] . Toilet transfer [code 02] . The MDSC stated Resident 1's MDS indicated the resident required the assistance of two people to safely transfer between the bed and chair and the chair to toilet. Resident 1's fall risk care plan dated 3/25/25, was reviewed. The care plan indicated, . functioning deficit related to: Mobility impairment, ROM [range of motion] limitations r/t fracture to right superior/inferior pubis ramus . Interventions . Bed mobility assistance . Call bell within reach . Toileting Assistance . Transfer Assistance . Resident 1's fall care plan dated 5/19/25, was reviewed and it indicated, . At risk for delayed trauma r/t actual fall on 5/19/25 at 12:30 PM 1st and 2nd fall at 5:03 PM . 72 hour alert monitoring . Floor mat next to bed . evaluation of the resident's condition . activity programs . low electric bed . Manage resident fall risk through facility Red Sneaker Program . Resident 1's fall care plan dated 6/17/25 was reviewed and it indicated, . At risk for delayed injury r/t actual fall on 6/16/25 . Assist with toileting q [every] 2 hrs [hours], at bed time and as needed . floor mats to side of bed . level 2 [every 15 minute checks] monitoring x 72 hours . Notify hospice . Encourage activities . Resident 1's fall risk care plan dated 7/16/25, indicated, . At risk for unavoidable falls and related injury . Rt. [right] Hip fracture R/T [related to] Osteoporosis/Diffuse Osteopenia . Resident is on Hospice care . Bed in low position . Fall Mat. Turn and reposition Q [every] 2 hours . The MDSC stated the care plan interventions were not personalized to Resident 1's needs. The MDSC stated rounding on residents and offering to toilet the residents every two hours was standard care and did not specifically address Resident 1's frequent urination or attempts to self-transfer.During a concurrent interview and record review on 8/1/25 at 11:55 a.m. with the DON, the DON stated Resident 1 was at high risk for falls and was admitted with fractures from falling prior to admission. The DON stated Resident 1 was not compliant with care and would try to transfer herself because she felt like she needed to use the restroom frequently. The DON stated Resident 1 was anxious, had behaviors of repeatedly requesting to use the restroom and attempting to self-transfer without assistance because she had urinary urgency, increasing her fall risk. The DON stated the CNAs would take Resident 1 to the bathroom and five minutes later she would get restless and want to go again. The DON stated Resident 1 had been seen by a psychologist (a professional who studies mental processes and behavior) to address the behavior of anxiety causing repeated requests to use the toilet. The DON reviewed Resident 1's electronic medical record and stated Resident 1 did not have a urinalysis (U/A-laboratory test that examines a person's urine to detect and assess various health conditions) to rule out a possible infection as a cause for her urinary urgency. The DON stated a U/A was not tested because Resident 1 was on hospice. The DON reviewed Resident 1's fall care plans and stated the resident sustained four falls while at the facility. The DON was unable to find interventions indicating how the plan of care addressed Resident 1's urinary urgency and frequency and her attempts to self-transfer. Resident 1's General Note, dated 6/17/25, was reviewed. The note indicated, . LATE ENTRY . Writer was notified by staff that resident was sitting on the floor . Resident stated I slid from bed and fell. I wanna go to the bathroom, I need to pee . Resident 1's SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] Post Fall, dated 6/16/25 at 11:30 p.m., indicated, . Resident fell in Resident room. Unwitnessed fall . The DON stated the root cause of Resident 1's 6/16/25 fall was the resident's attempt to transfer unassisted because she needed to go to the bathroom. The DON was unable to state if any new, personalized interventions were put into place after the fall on 6/16/25. Resident 1's SBAR Post Fall, dated 7/16/25 at 3:46 p.m. was reviewed and indicated, . Prior to fall resident was Attempt to self transfer . Resident fell in Resident room . Injury . Unwitnessed fall . Fall details: Other Unable to describe . from 7/16/25 was reviewed and indicated, . The DON stated Resident 1's fall was unwitnessed. The DON stated a new intervention was put into place after the fall and Resident 1 was moved into a different room with a CNA assigned in the room for the day and evening shifts. During a review of Resident 1's Psychologist Consultation, dated 6/23/25, . Treatment & compliance . demanding . Affect . Anxious . anxious [with] frequent requests to use restroom .During a review of Resident 1's Post Fall IDT Analysis, Dated 6/19/25, the note indicated, . Fall Date and Time . 6/16/25 . LN was notified by staff that resident was sitting on the floor. LN went to res. room assessed resident, noted this res sitting on the floor leaning her back against the bed .During a review of Resident 1's Psychologist Consultation, dated 7/15/25, . Treatment & compliance . repetitive requests . Affect . Anxious . anxious, forgetful, has frequent requests to use toilet is otherwise cooperative with care & Tx [treatment].During a review of Resident 1's Post Fall IDT Analysis, dated 7/16/25, the IDT note indicated, . Fall Date and Time . 7/16/25 at 06:15 [a.m.] . Immediate interventions post fall . Placed on level 2 monitoring. Hospice Nurse Came New orders for pain meds [medication]. Xray Rt. [right] Leg and Rt. Hip . C/O [complains of] pains Room Change offered for close supervision . At 06:15 AM staff found resident sitting on the floor mat. At 06:05 AM CNA made rounds & res. [resident] was on her bed with her call light within reach. LVN saw res. 10-15 minutes prior to fall. Root cause: Resident was restless and attempted to move from and in her bed and landed on her floor mat .During a review of Resident 1's pain care plan dated 7/16/25, the care plan indicated, . Acute Pain Fracture-Right hip fx [fracture] . Administer Morphine routinely as ordered . Observe for loss of appetite . Utilize non-medication interventions for pain relief . Utilize positioning and relaxation techniques for comfort .During a review of Resident 1's mobility care plan dated 7/16/25, the care plan indicated, . Impaired physical mobility related to acute intertrochanteric fracture of the right hip . Assess for pain regularly . Ensure fracture precautions are communicated . Inspect fracture site for swelling, discoloration or increased tenderness . Maintain toileting schedule .During a review of Resident 1's Order Summary Report [OSR], dated 7/2025, the OSR indicated, . Monitor episode of Anxiety m/b [manifested by] repetitive request to use the restroom despite recently being assisted [Ordered 7/17/25] . Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for Pain [ordered 3/25/25] . Morphine Sulfate 20 mg/ml . Give 0.25 ml by mouth three times a day for Pain [ordered routinely on 7/17/25] . oxybutynin Chloride Oral Tablet [a medication to treat overactive bladder symptoms include frequency, urgency (sudden, compelling need to urinate), and incontinence (involuntary leakage of urine)] . give 1 tablet by mouth two times a day for overactive bladder for 1 Week over active bladder [ordered 7/17/25] . During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible . Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . Implementing interventions to reduce accident risks . Ensuring that interventions are implemented . Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs .During a review of the facility's P&P titled Falls-Clinical Protocol, dated 9/2012, indicated, . As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling . many falls are isolated individual incidents, a significant proportion occur among a few residents . individuals may have a treatable medical disorder or functional disturbances as the underlying cause . After more than one fall, the physician should review the resident's gait, balance, and current medications . staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found. Based on the preceding assessment, the staff and physician will identify pertinent interventions or try to prevent subsequent falls and to address risks of serious consequences of falling . If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment . until falling reduces or stops or until a reason is identified . (for example, if the individual continues to try to get up and walk without waiting for assistance) . The staff . will follow up on any fall with associated injury until the resident is stable . Frail elderly individuals are often at greater risk for serious adverse consequences of falls . If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed . If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse for one of four sampled residents (Resident 1) when Resident 1 experienced an incident on 10/26/23 where Resident 2 entered Resident 1 ' s room, unattended and unsupervised, and used a stuffed cat/toy that belonged to Resident 1 to inflict facial and eye injuries. On 2/1/24, Resident 1 was found to have facial and eye injuries of unknown origin. The unwitnessed incident resulting in Resident 1 ' s facial injuries was not reported immediately by CNA 1 in accordance with facility policy and procedure. These failures resulted in Resident 1 to experience avoidable physical, psychosocial, and emotional harm. Resident 1 experienced discomfort and pain that required treatment over several days to heal, and transfer to a higher level of care to the local acute care hospital emergency room on 2/4/2024 for further evaluation. Findings: During a review of Resident 1's admission Record (AR - document containing resident demographic information and medical diagnosis), dated 2/2/24, the admission record indicated Resident 1 was admitted to the facility on [DATE] from the acute care hospital with diagnoses which included Alzheimer ' s Disease (loss of memory and ability to carry simple tasks), Protein Calorie Malnutrition (not consuming enough protein and calories), Type 2 Diabetes Mellitus (high blood sugar), Muscle Weakness, Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Dementia with mood disturbance (impaired ability to remember, think, or make decisions), and Psychosis (symptoms that happen when a person is disconnected from reality, it may involve hallucinations or delusions). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident mental and physical function) assessment dated [DATE], Resident 1 ' s MDS assessment indicated Resident 1 ' s cognitive (memory) skills for daily decision-making was severely impaired. The MDS mobility assessment indicated Resident 1 was dependent on staff when repositioning from laying on back to the left and right side and return to laying back in bed. Resident 1 was chairbound and bedbound and could not make needs known to staff. During a review of Resident 1 ' s Progress Note (PN) and Care Plan (CP) dated 10/26/23, the PN indicated, . At around 4:30 a.m., writer heard CNA calling for help in [Resident 1] ' s room, writer immediately ran to [Resident 1] ' s room, staff was bringing out [Resident 2, alleged abuser] out of [Resident 1] ' s room, [Resident 1] was yelling as the staff while holding a cat stuffed toy. [Resident 2] was transferred to activity room. [Resident 1] was screaming and yelling as well. Unable to obtain statement as to resident speak limited English and [Foreign Language]. Per [Resident 2] Resident 1 needs to shut up from screaming. Per CNA report [Resident 2] was standing in front of Resident 1 holding a stuff toy and putting it in resident mouth . CP . RESOLVED: STOP: [Resident 1] was hit by other resident [Resident 2] on face with stuffed toy while lying in bed, noted bruise to right upper lip; at risk for delayed ill effect . Interventions: Notify MD [Physician], RR [Responsible Party], Ombudsman and PD [Police Department] . Monitor for s/s [sign and symptoms] of pain and administered pain medication as ordered . Separate resident from other resident . There was no documented evidence in the PN the incident was reported to the California Department of Public Health. During a review of Resident 2's AR, dated 2/21/24, the admission record indicated Resident 2 was admitted to the facility on [DATE] from a long term care hospital with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- is a chronic inflammatory lung disease that causes obstructed airflow of the lungs), Dementia, Psychosis, Delusional Disorders (a belief that is firmly maintained despite being contradicted by what is generally accepted as reality), Anxiety (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness) and Hypertension (high blood pressure). During a review of Resident 2's MDS assessment dated [DATE], Resident 2's MDS indicated Resident 2 ' s, Brief Interview for Mental Status (BIMS) Summary Score of 4 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 2 ' s cognitive impairment was severe. The MDS behavior assessment indicated Resident 2 has a behavior of being physically aggressive towards other residents such as hitting, kicking, scratching, grabbing, and abusing others and wandering inside the facility. During a review of Resident 1' s Change of Condition (COC) and PN, dated 2/1/24, the COC and PN indicated, . COC . Noted bruising to left cheek and left eye and jaw. Skin tear to right side of nose . PN . Today around 10 p.m. the resident ' s CNA [Certified Nurse Assistant] let the writer know that the resident had swelling to her left cheek. Upon assessment of the resident ' s skin, it was noted that the resident had bruising to both her cheeks, left eye and left side of her jaw. The resident also had swelling to both her cheeks as well and a horizontal scratch to the right side of her nose . The hospice nurse ordered an ice pack be applied to bilateral cheeks to help reduce the swelling . [Signed LVN 1] . During a concurrent observation and interview on 2/2/24, at 9:41 a.m., with Certified Nurse Assistant (CNA) 2 inside Resident 1 ' s room. Resident 1 was observed sleeping in her bed. CNA 2 stated Resident 1 was started on 1:1 monitoring this morning. CNA 2 stated, [Resident 1] has bruising on her left and right cheeks, below her eyelids. A scratch below her left eye and both of her cheeks are swollen. I was told that the source of her injury was unknown. CNA 2 stated Resident 1 had history of yelling and physical aggression towards staff but no history of hurting herself. During a concurrent observation and interview on 2/2/24, at 9:47 a.m., with CNA 2, inside Resident 1 ' s room, Resident 1 was observed with swollen and purple discoloration around her left and right eyes, left cheek and with a horizontal scratch below her left eye. Resident 1 was observed sleeping in her bed and a brown and white cat stuffed toy was on top of the overbed table and within reach of Resident 1 and to anyone entering the room. The cat stuffed toy was approximately four pounds in weight and made of soft and hard plastic materials. CNA 2 stated the cat stuffed toy was used to keep Resident 1 occupied while in her room. During a concurrent interview and record review on 2/2/24, at 9:54 a.m., with Registered Nurse (RN) 1, Resident 1 ' s PN, dated 2/1/24 was reviewed. The PN indicated, . Today around 10 p.m. the resident ' s CNA [Certified Nurse Assistant] let the writer know that the resident had swelling to her left cheek. Upon assessment of the resident ' s skin, it was noted that the resident had bruising to both her cheeks, left eye and left side of her jaw. The resident also had swelling to both her cheeks as well and a horizontal scratch to the right side of her nose . RN 1 stated Resident 1 was started on 1:1 monitoring at the beginning of her shift, medicated for pain, and staff were applying ice pack to Resident 1 ' s face. RN 1 stated Resident 1 has a history of yelling, screaming, and fighting with staff during personal care but no history of hurting herself. RN 1 stated Resident 1 and her roommates were both bedbound and non-ambulatory. RN 1 stated, I don ' t know how it happened. RN 1 stated all staff are responsible in protecting Resident 1 and other residents from harming themselves or getting hurt by others. During a phone interview on 2/2/24, at 11:05 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she worked on 2/1/24 and was the assigned nurse for Resident 1. LVN 1 stated [CNA 1] reported to her that Resident 1 has bruising, swelling and scratches on her face. LVN 1 stated [CNA 1] discovered the bruising at 7:00 p.m. but did not report to her until 10 p.m. LVN 1 stated she went immediately to Resident 1 ' s room and performed an assessment. LVN 1 stated, [Resident 1] had bruising to both cheeks, left eye and left side of jaw. [Resident 1] also had swelling to both her cheeks as well and a horizontal scratch to the right side of her nose. I called the doctor, hospice agency, Director of Nursing (DON), and the Responsible Party (RP). The hospice nurse came and ordered to apply ice pack to the swollen area. LVN 1 stated prior to the reported incident, she gave Resident 1 ' s 5:00 p.m. [evening] medications and did not observe any facial bruising, swelling or skin discoloration. LVN 1 stated everyone who works in the facility was responsible in protecting residents from harm. LVN 1 stated the facility failed to protect Resident 1 from harming herself or getting hurt by others. During a phone interview on 2/2/24, at 11:13 a.m., with CNA 1, CNA 1 stated she worked on 2/1/24 and was the assigned CNA for Resident 1 from 7:00 p.m. to 10:40 p.m. CNA 1 stated, I saw her at 7:30 p.m. and I noticed the bruising on both of her cheekbones, upper side. She was being aggressive and combative. I left the room and provided care to other residents. I returned to [Resident 1 ' s] room to change her disposable brief around 9:00 pm, [CNA 3] assisted me with changing the brief. I told her about my observation, and she told me to notify the Charge Nurse of the bruising. I reported my observation to [LVN 1] around 10 p.m. I don ' t want to be blamed for it. I forgot to report the bruising right away. I should have reported it as soon as I noticed the bruising and I did not. CNA 1 stated she doesn ' t recall if another resident or staff went to Resident 1 ' s room during her shift. CNA 1 stated she failed to follow the facility ' s policies on reporting alleged abuse and change in condition. During an interview on 2/2/24, at 11:35 a.m., with CNA 4, CNA 4 stated she worked on 2/1/24, from 6:00 a.m. to 6:55 p.m., and was the assigned CNA for Resident 1 from 2:30 p.m. to 6:55 p.m. CNA 4 stated she was the Restorative Nurse Assistant (RNA, assist residents with range of motion exercises) from 6:00 a.m. to 2:30 p.m., then worked for additional four hours to assist the afternoon shift with patient care. CNA 4 stated she delivered Resident 1 ' s dinner around 5:00 p.m. Resident 1 was sleepy and refused her meal. CNA 4 stated she did not notice any bruising on her face and was not in pain. CNA 4 stated, She was just sleepy. Normally, she will be screaming and yelling in her native language. [Resident 1] is total care. Bedbound. She needs assistance during meals. No history of hurting herself. A possibility is someone came to her room and hurt her. We don ' t have a video recording to support my statement. We don ' t have a camera in our hallway.CNA 4 stated Resident 1 was physically abused by Resident 2 several months ago [10/2023] and suffered multiple bruises on her face. CNA 4 stated, This is not the first time that [Resident 1] was hurt by another resident. CNA 4 stated all staff, including her were responsible in preventing resident abuse and the facility failed to protect Resident 1 from abuse. During a phone interview on 2/2/24, at 12:30 p.m., with CNA 3, CNA 3 stated she worked on 2/1/24 and assisted CNA 1 in changing Resident 1 ' s brief around 9:00 p.m. CNA 3 stated she was walking in the hallway, outside Resident 1 ' s room and she heard CNA 1 talking to Resident 1. CNA 3 stated, I knocked and entered the room and found CNA 1 changing Resident 1 ' s disposable brief. I offered to help by holding Resident 1 ' s back while CNA 1 puts on a new brief. CNA 1 told me that she noticed some bruising on Resident 1 ' s face at the beginning of her shift but forgot to report to the Charge Nurse. I advised her to immediately notify the Charge Nurse. CNA 3 stated it is important to report the observed bruising for immediate assessment, treatment interventions, investigation, and to protect the resident from further harm. CNA 3 stated she did not examine Resident 1 ' s face because she was called by another Resident who was asking for help. CNA 3 stated, We have several residents with history of aggression towards other residents who are ambulatory and wander inside the facility and enter other residents ' room. During a concurrent observation and interview on 2/6/23, at 1:22 p.m., with CNA 5, inside Resident 1 ' s room. Resident 1 was observed with purple color skin around her left and right eye, her left cheek was purple in color, a horizontal scratch below her left eye with tinge of dried blood, and a bruising on her right hand. Resident 1 was observed sleeping in her bed and a brown and white cat stuffed toy was on top of the overbed table and within reach of Resident 1 and to anyone entering the room. CNA 5 stated Resident 1 remains on 1:1 monitoring, and the cat stuffed toy was used to keep Resident 1 occupied while in her room. CNA 5 reported Resident 1 sustained bruising on her right hand this morning, around 6:00 a.m. CNA 5 stated Resident 1 was swinging her right arm and hand during patient care and hit the bed side rail. During a concurrent phone interview and record review on 2/16/24, at 11:40 a.m., with Registered Nurse Supervisor (RNS), Resident 1 ' s PN, dated 2/1/24 was reviewed. The PN indicated, . Today around 10 p.m. the resident ' s CNA let the writer know that the resident had swelling to her left cheek. Upon assessment of the resident ' s skin, it was noted that the resident had bruising to both her cheeks, left eye and left side of her jaw. The resident also had swelling to both her cheeks as well and a horizontal scratch to the right side of her nose . RNS stated Resident 1 has a history of hitting, swinging, and grabbing staff during personal care. RNS stated Resident 1 has no documented record of hurting herself. RNS stated CNA 1 failed to report the observed facial bruising in a timely manner. RNS stated the delay in reporting prevented the facility to implement appropriate interventions to protect Resident 1 from potential additional harm and delay in the investigation of the alleged abuse incident. RNS stated Resident 1 was physically abused by [Resident 2, perpetrator] four months [10/26/23] ago that resulted in facial bruising and swelling. RNS stated Resident 2 remains a resident at the facility and continues to wander inside the facility. RNS stated Resident 1 remains to have a circular discoloration around her left and right eyes, purple color in the middle and yellow color on the outer part. RNS stated Resident 1 ' s 1:1 monitoring did not start until the morning shift of 2/2/24. RNS stated the facility failed to protect Resident 1 from harm that resulted in facial bruising and swelling for several days, requiring emergency room visit, treatment and pain medication. During a review of Resident 1 ' s Acute Care After Visit Summary dated 2/4/24, the visit summary indicated, . You were seen for bruising below your eyes. Your CT scan [Computed Tomography, imaging test to detect internal injuries or disease] did not show bleeding or a broken bone . Diagnosis . Periorbital ecchymosis [black eye, often happens form an injury to the area around the eye] . [emergency room Provider] . During a concurrent phone interview and record review on 2/16/24, at 11:52 a.m., with RNS, Resident 1 ' s CP, dated 10/26/23 was reviewed. The CP indicated, . CP . RESOLVED: STOP: Resident was hit by other resident on face with stuffed toy while lying in bed, noted bruise to right upper lip; at risk for delayed ill effect . Interventions: Notify MD, RP, Ombudsman and PD . Monitor for s/s [sign and symptoms] of pain and administered pain medication as ordered . Separate resident from other resident . RNS stated Resident 1 was vulnerable for physical abuse from other residents due to her behavior of continuous yelling and screaming. RNS stated she can ' t find a specific care plan to protect Resident 1 from physical abuse from other residents and there should have been one. RNS stated without a specific care plan to prevent physical abuse, Resident 1 could potentially experience physical abuse from other residents. During a phone interview on 2/16/24, at 12:20 p.m., with the Director of Staff Development (DSD), the DSD stated CNA 1 failed to report Resident 1 ' s bruising on 2/1/24 in a timely manner. The DSD stated she expects CNA 1 to report any observed bruising immediately to the charge nurse and she did not. The DSD stated Resident 1 was abused by Resident 2 on October 26, 2023, which resulted in Resident 1 to have bruising and swelling around her eyes and mouth. The DSD stated Resident 2 remains a resident at the facility and continues to wander inside the facility. The DSD stated everybody is responsible in protecting Resident 1 from physical abuse and failed to do so. During a phone interview on 2/16/24, at 12:20 p.m., with Resident 1 ' s daughter/ Responsible Party (RP), the RP stated [Resident 1] was admitted to the facility on [DATE] from acute hospital. RP stated [Resident 1] was bedbound, dependent on staff for her personal care, and under hospice care. RP stated [Resident 1] was physically abused twice at the facility that resulted to facial bruising, swelling, and affected her quality of life. RP stated [Resident 1] has a history of refusing care by kicking and hitting staff during personal care but no history of harming herself. RP stated she and [Resident 1 ' s] spouse visit the facility on a weekly basis and witnessed on multiple occasions other residents wandering insider Resident 1 ' s room and touching her belongings. RP stated, The facility did not do enough to protect my mom from physical abuse on October 26, 2023, and on February 1, 2024. She ' s under hospice and our goal is to keep her safe. She got hurt twice. It ' s heart-breaking. I hope they do something to protect her from future harm. During a concurrent interview and record review on 2/23/24, at 10:20 a.m., with the Director of Nursing (DON), Resident 1 ' s CP and PN, dated 10/26/23 and 2/1/24 were reviewed. The PN indicated, . 10/26/23 . at around 4:30 a.m., writer heard CNA calling for help in [Resident 1 ' s] room, writer immediately ran to [Resident 1] ' s room, staff was bringing out [Resident 2] out of [Resident 1 ' s] room, [Resident 1] was yelling at the staff while holding a cat stuffed toy . 2/1/24 . Today around 10 p.m. the resident ' s CNA let the writer know that the resident had swelling to her left cheek. The DON stated Resident 1 was bedbound and dependent to staff for all areas of ADLs. The DON stated Resident 1 has no history of hurting herself. The DON stated she was unable to find a specific CP to address Resident 1 ' s vulnerable condition and the potential for physical abuse from other residents. The DON stated the CP should have been initiated on admission and it was not done. The DON stated the physical abuse to Resident 1 on 10/26/23 and 2/1/24 could have been prevented if the proper interventions were in place. The DON stated the facility failed to protect Resident 1 from physical, psychological, and emotional harm. During a review of the facility's document titled, Certified Nurse Aide Job Description, dated 9/25/14, the document indicated, . Perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting a compassionate physical and psychosocial environment for resident . During a review of the facility's document titled, Job Description: Charge Nurse Licensed Vocational Nurse (LVN), dated 8/14/15, the document indicated, . Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices . Must adhere to the Company ' s Code of Conduct and Business Ethics policy including documentation and reporting responsibilities . During a review of the facility document titled, Job Description: Charge Nurse Registered Nurse (RN), dated 8/17/15, the Job Description indicated, . Assure the effective quality nursing care is delivered . Develop individualized plan of care in collaboration with the resident/responsible party and interdisciplinary care team . Demonstrate understanding that state and Federal rules and regulations govern the practices within the facility . During a review of the facility document titled, Job Description: Director of Nursing (DON), dated 10/15/14, the Job Description indicated, . Plans, coordinates, and manages the nursing department. Responsible for the overall direction, coordination and evaluation of nursing care and services provided to residents. Maintains quality care that is consistent with company and regulatory standards . Oversees and monitors the Resident Assessment process for accuracy, attends care planning conferences periodically to determine compliance with care planning guidelines . During a review of the facility ' s document titled, Your Legal Duty . Reporting Elder and Dependent Adult Abuse, dated 2/23, the document indicated, . Failure to report elder or dependent adult abuse in long-term health care facilities is a crime . This training curriculum has been developed by the Department of Justice, in cooperation with the Department of Health Care Services and the Department of Social Services . During a review of the facility ' s policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated 7/17, the P&P indicated, . All reports of resident abuse, neglect, exploitation . shall be promptly reported to local, state, and federal agencies . Findings of abuse investigations will also be reported . During a review of the facility ' s policy and procedure (P&P) titled, Recognizing Signs and Symptoms of Abuse/Neglect, dated 2/11, the P&P indicated, . Our facility will not condone any form of resident abuse or neglect. To aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately . Signs of Actual Physical Abuse: (1) Welts or bruises; (2) Abrasions or lacerations . (4) Black eyes or broken teeth . During a review of the facility ' s P&P titled Resident-to-Resident Altercations (disputes), dated 2/16, the P&P indicated, .All altercations, including those that may represent resident-to-resident abuse, shall be investigated, and reported to the Nursing Supervisor, the Director of Nursing Services and to the Administrator . Policy Interpretation and Implementation . 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff . shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policies and procedures regarding the safe and appropriate prescribing and administering of antipsychotic (medications used to treat psychosis-which is a condition that affects the mind, where there has been some loss of contact with reality) medications and ensure three of three sampled residents (Resident 38, Resident 47, and Resident 150) were free from unnecessary medications when: 1. For Resident 47, staff administered Aripiprazole (an antipsychotic medication used to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality) without monitoring for side effects. 2. For Residents 38, 47, and 150, the facility did not implement resident specific non-pharmacological (without the use of medications) interventions prior to initiation of antipsychotic medications. These failures had the potential for Residents 38, 47, and 150 to experience the serious negative effects (medication interactions, adverse reactions, dizziness [increasing risk for falls], drowsiness, high cholesterol, high blood sugar [increasing risk for diabetes - high sugar in the blood]), liver dysfunction, weight gain, constipation, heartburn, dry mouth, akathisia (a state of agitation, distress, and restlessness), weakness, Neuroleptic Malignant Syndrome (NMS, a life threatening reaction from use of antipsychotic medication), tardive dyskinesia (uncontrolled body movements), decreased blood pressure, seizures and difficulty swallowing, pseudo parkinsonism (a medical condition causing slowed movements, muscle stiffness, and a shuffling walk), and ingestion of anti-psychotics. For Resident 47, the unnecessary use of Aripiprazole resulted in the development of hyperglycemia (high blood sugar) from 7/8/22 to 7/11/22 and hospitalization on 7/11/22 due to hyperglycemia; and constituted harm as a result of administering Aripiprazole. Findings: 1. During a review of Resident 47's admission Record (AR), dated 7/13/22, the AR indicated Resident 47 is a [AGE] year old male who was admitted from a general acute care hospital (GACH) on 12/16/21 to the facility, with diagnoses which included type 2 diabetes mellitus (a disease that occurs when your blood sugar is too high), anxiety disorder, chronic kidney disease (gradual loss of kidney function over time), hyperlipidemia (too many fats in your blood), unspecified dementia (the loss of memory, language, problem solving and thinking abilities) without behavioral disturbance, hypertensive (high blood pressure) heart disease without heart failure, constipation, and pain. During an observation on 7/11/22, at 11:33 a.m., inside Resident 47's room, Registered Nurse (RN) 1 checked Resident 47's blood sugar and the glucometer (portable device used to measure how much sugar is in the blood) read HI (maximum on glucometer). RN 1 stated she was unable to get a reading on the glucometer because Resident 47's blood sugar was very high and Resident 47's physician (PHY 1), had instructed her to send Resident 47 to the GACH. During a concurrent interview and record review, on 7/12/22, at 2:22 p.m., with RN 1, Resident 47's Order Summary Report (OSR), dated 6/30/22 was reviewed. The OSR indicated on 7/5/22 Buspirone (medication used to treat anxiety) was discontinued, and Resident 47 was prescribed Aripiprazole 5 milligrams (mg-unit of measure) by mouth once daily on 7/5/22 for diagnosis of brief psychosis. RN 1 stated Resident 47 was on Buspirone 5mg and was still having behaviors, so his dose was increased to 10mg. RN 1 stated, [Resident 47] continued to have behaviors which include talking loudly and if you approach him, he becomes aggressive . RN 1 stated she was aware of the black box warning stating Aripiprazole could cause an increased mortality for residents with dementia related psychosis. RN 1 stated Resident 47 had dementia, so he would fall in this category. RN 1 stated Resident 47's blood sugars were mainly in the 100-200's but had recently started increasing on 7/8/22 to the 400-500's range (normal blood sugar level is less than 140). During an interview on 7/12/22, at 2:49 p.m., with RN 1, RN 1 stated side effects to monitor for Aripiprazole included: drowsiness, weight gain, hyperglycemia, dry mouth, constipation, and risk for stroke. RN 1 stated licensed nurses (LN) were not monitoring the side effects for Aripiprazole because she forgot to update the monitoring on Resident 47's electronic medical record (EMR). RN 1 stated it was important to monitor the side effects of Aripiprazole because of the fatality that could occur which could include death. RN 1 stated if a resident was having bad side effects due to a new medication and LN were not monitoring for side effects, LN would not be able to detect that the resident was experiencing side effects. During an interview on 7/12/22, at 3:07 p.m. with RN 1, RN 1 stated hyperglycemia was a side effect of Aripiprazole which could cause an increase in blood sugar levels. RN 1 stated, If I notice an increase in blood sugars, I should notify the physician. RN 1 stated she would inform the physician Resident 47's blood sugars were high and the date the Aripiprazole was started. RN 1 stated if she was monitoring side effects related to Aripiprazole, she would have noticed when Resident 47 was having side effects to Aripiprazole. RN 1 stated Resident 47 had not been monitored for involuntary movements and had not had any eye exams since he has been admitted to the facility. During a concurrent interview and record review on 7/12/22, at 3:57 p.m., with the Director of Nursing (DON), Resident 47's Psychologist Consultation/Follow up, dated 3/14/21 was reviewed. The DON stated Resident 47's Psychologist Consultation/Follow up indicated, .easily agitated, yells at staff, not combative, no antipsychotic medications recommended . The DON stated psychological evaluations were done every six months. The DON stated the side effects of Aripiprazole were not being monitored for Resident 47. The DON stated some common side effects of aripiprazole included sedation, dry mouth, blurred vision, weight gain, postural hypotension, sweating, loss of appetite, urinary retention, and drowsiness. The DON stated side effects such as abnormal voluntary movements were not being monitored for Resident 47. The DON stated second generation antipsychotics (such as Aripiprazole) could cause hyperglycemia and was serious enough to warrant monitoring. The DON stated hyperglycemia was not monitored by LN as a possible side effect of Aripiprazole. The DON stated the blood sugar drawn was previously ordered for Resident 47's diabetes. The DON stated it was important to monitor side effects to evaluate medication cessation (to stop). The DON stated her expectations were for LN to have the knowledge that hyperglycemia was a side effect of Aripiprazole. The DON stated she was aware of the black box warning for Aripiprazole used in residents with dementia. During a review of Resident 47's Weights and Vitals Summary (WVS), dated 7/13/22, the WVS indicated Resident 47's blood sugars on 6/4/22 were 104 and 145, on 6/11/22 were 136 and 201, on 6/18/22 were 198 and 216, and on 6/25/22 were 198 and 148. During a concurrent interview and record review on 7/12/22, at 4:30 p.m. with DON, Resident 47's Medical Record (MR), undated was reviewed. The MR indicated on 7/2/22 blood sugars were 144 and 188, on 7/7/22 blood sugars were 162, on 7/8/22 blood sugars were 569, 414, and 275, on 7/9/22 blood sugars were 400, 430, and 415, on 7/10/22 blood sugars were refused, on 7/11/22 blood sugar was HI and Resident 47 was sent to GACH. The DON stated Resident 47's diet was the same and he did not have any previous infections. During a review of Resident 47's hospital After Visit Summary (AVS), dated 7/11/22, the AVS indicated .[Resident 47] was seen today for high blood sugar. He was given IV [Intravenous -in the vein] fluids and insulin and his sugar came down .will need close outpatient follow up with his doctor to better manage his blood sugar . During a review of Resident 47's hospital Summary of Care (SOC), dated 7/11/22, the SOC indicated .Basic Metabolic Panel .glucose 658 . During an interview on 7/14/22, at 1:10 p.m., with PHY 1, PHY 1 stated Resident 47's Buspirone 10mg was not titrated to max dose because Resident 47 was on 5mg BID (twice a day) then 10mg BID and his behaviors got much worst over time and Resident 47 was refusing medications and care, so it was PHY 1's decision to switch from Buspirone to Aripiprazole 5mg. PHY 1 stated he has ordered Aripiprazole for other residents for a long time and none of those residents has had a dramatic increase in blood sugar. PHY 1 stated he was aware there were no changes to Resident 47's diet to cause the fluctuation. PHY 1 stated he assumed there was something else going on and Resident 47 was seen and evaluated in the emergency department, but they could not find the cause for the high blood sugar, so he assumed it was because of the Aripiprazole. PHY 1 stated he had used Ariprazole on his patients for over 15 years and agitation had not been an issue for those residents. PHY 1 stated his expectations were for LN to assess residents' baseline scale for abnormal involuntary movements. PHY 1 stated Resident 47 was sent to GACH because the outcome of having a blood sugar over 600 could be a devastating problem. During an interview on 7/14/22, at 3:45 p.m., with the Consultant Pharmacist (CP), the CP stated it was important to assess AIMS (abnormal involuntary movement scale- scale used to measure abnormal movements in a patient taking antipsychotics) which could cause long term effects. The CP stated it was important to monitor visual acuity for residents who were on antipsychotics to see if their vision was getting worse due to the medications. The CP stated it was important to monitor side effects to determine if the medication needed to be discontinued, a dosage increase, or gradually reduce the dose. During a review of a nationally recognized professional reference titled, Lexicomp, the drug manufacturer for Aripiprazole stated, .WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect .High blood sugar like confusion . Monitoring Parameters . Frequency of Antipsychotic Monitoring . Extrapyramidal symptoms . 4 weeks after initiation and dose change; annually. Use a formalized rating scale at least annually or every 6 months if high risk . Obtain ophthalmic exam (yearly in patients >40 years . 2a. During an interview on 7/12/22, at 3:07 p.m. with RN 1, RN 1 stated nonpharmacological interventions for Resident 47 included leaving him alone when he was having behaviors to allow Resident 47 to calm down. RN 1 stated she did not document all the nonpharmacological interventions implemented for Resident 47. RN 1 stated usually when residents are having behaviors, she does behavior monitoring and would offer food and fluids. During a review of Resident 47's MAR, dated June 2022 and July 2022 was reviewed. The MAR indicated in June 2022, Resident 47 had 13 episodes of behaviors with interventions implemented to include: back rub, change position, give fluids, give good or redirect. The MAR indicated in July 2022, Resident 47 had 20 episodes of behaviors with interventions implemented to include: one on one, activity, or give fluids. During a concurrent interview and record review on 7/12/22 at 3:30 p.m., with RN 1, Resident 47's Care Plan (CP), dated 7/6/22 and the facility document Side Effects Monthly Flow Sheet, undated was reviewed. The CP indicated, on 7/6/22, the focus was: I sometimes have behaviors, such as persistent distress of being territorial over people or items thinking it belongs to me AEB [as evidenced by] verbal & [and] physical aggression when I feel my belongs are threatened .as a diversion, talk to me about my interests. Such as sports and basketball, singing or offer me something I like as a diversion, such as singing, dominoes, and eating all kinds of sweets .elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis .monitor for side effects and report to physician: Antipsychotic medication-sedation, drowsiness, dry mouth, constipation, blurred vision, EPS [extrapyramidal symptoms-serious side effects that can develop after taking certain antipsychotic medications], weight gain, edema, postural hypotension [low blood pressure that happens when standing after sitting or lying down), sweating, loss of appetite, urinary retention (condition in which you cannot empty all the urine in the bladder] .monitor HR [heart rate] & BP [blood pressure], abdominal girth and labs as ordered while on antipsychotic medication .Non-pharmacological interventions: See flow sheet .provide medications as ordered by physician and evaluate for effectiveness through behaviors management program . RN 1 stated the care plan for non-pharmacological interventions should be person centered care plans or resident specific interventions because one intervention does not necessarily work for all residents. RN 1 stated the Side Effects Monthly Flow Sheet was a general list of interventions which were not resident centered care and there were no target end dates. RN 1 stated if she did not document the resident specific interventions implemented then other staff would not know which interventions to implement to help the resident. During a concurrent interview and record review on 7/12/22, at 3:57 p.m., with the DON, Resident 47's Electronic Medical Record (EMR), undated, the DON stated the EMR indicated on 7/3/22 at 7:27 a.m., Resident 47 was yelling, cursing, hard to re-direct and he was offered food and fluids to distract him. The DON stated offering food and fluids was not a resident specific intervention and the DON stated nonpharmacological interventions should be resident specific. The DON stated nonpharmacological interventions should be documented and it was important to document non-pharmacological interventions so LN would know which interventions were effective and they could implement those interventions instead of using pharmacological interventions. 2b. During a review of Resident 38's AR, dated 7/14/22, the AR indicated Resident 38 is an [AGE] year old female who was admitted from an assisted living facility on 5/12/17 to the facility, with diagnoses which included type 2 diabetes, hypertension (high blood pressure), major depressive disorder, hyperlipidemia, dysphagia (difficulty swallowing), dementia with behavioral disturbance, paranoid personality disorder (condition marked by a pattern of distrust and suspicion of others without adequate reason to be suspicious), and anxiety disorder. During a concurrent interview and record review on 7/14/22, at 1:52 p.m. with RN 1 and DON, Resident 38's Clinical Physician's Orders (CPO), dated 7/14/22 was reviewed. The CPO indicated on 5/17/17, Risperidone 25 mg IM (intramuscular-in the muscle) every 14 days was ordered for paranoid personality disorder and then it was discontinued on 5/25/17. RN 1 stated there were several changes to the Risperidone order and on 12/18/20, Risperidone 0.5 mg BID (two times a day) was ordered and has been the same dose since then. RN 1 stated on 6/28/21, there was a gradual dose reduction (GDR-gradual reduction of medication) review but there was no GDR done. The DON stated a GDR was not done because it was done twice before, and Resident 38 had increased behaviors both times. DON stated PHY 2 signed off for GDR on 7/8/22 but when the LN called family of Resident 38 to inform them of the GDR, Resident 38's family communicated that Resident 38 was in distress and had increased behaviors the last time a GDR was done, and they did not agree to the GDR, so the GDR was not performed. During a review of Resident 38's MAR, dated June 2022 and July 2022, the MAR indicated Resident 38 had 18 episodes of behaviors in June [2022] and 8 episodes of behaviors in July [2022]. During a concurrent interview and record review on 7/14/22, at 2:30 p.m. with DON, Resident 38's Care Plan (CP), dated 7/14/22 and the facility's document titled Side Effects Monthly Flow Sheet, undated was reviewed. The DON stated Resident 38's CP indicated Resident 38 had resident specific nonpharmacological interventions and the facility used food as an intervention to divert Resident 38's behaviors to see if food was a need, that needed to be met. The Resident 38's CP indicated, .I sometimes have behaviors, such as delusion of thinking of others trying to harm me causing persistent distress AEB [as evidenced by] verbal & physical aggression towards others which puts me at risk for harm to self and others .interventions .as a diversion, talk to me about my interests. Such as, working as a teacher's aide, or offer me something I like as a diversion, such as Spanish music, a diet [brand name soda product], ice cream and Mexican food . The DON stated the Side Effects Monthly Flow Sheet is commonly used for all dementia residents and does not display resident specific nonpharmacological interventions. During an interview on 7/14/22 at 3:45 p.m. with the PC, the PC stated it was important for nurses to attempt nonpharmacological interventions and assessing residents for pain and offering as needed medications to see if they were effective because the interventions could reduce the need for antipsychotics and its side effects. During a review of the facility's policy and procedure (P&P) titled, Psychoactive Drug Monitoring, undated, the P&P indicated, .Residents who receive .antipsychotic medications are monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects . Residents who are receiving anti-psychotic drug therapy are adequately monitored for significant side effects of such therapy, through the use of the AIMS . 2c. During a record review of Resident 150's AR, dated 7/14/22, the AR indicated Resident 150 is a [AGE] year old female who was admitted from a GACH on 2/1/22 to the facility, with diagnoses which included spondylosis (a degenerative (causing the body part to become weaker) condition of the spine), asthma, hypertension, hyperlipidemia, anemia, dementia, unspecified psychosis not due to a substance or known physiological condition (a person's thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not), and low back pain. During a concurrent interview and record review on 7/13/22, at 9:43 a.m. with the DON, Resident 150's MAR, dated 7/14/22 was reviewed. The MAR indicated .Quetiapine [medication used to treat schizophrenia, bipolar disorder and major depressive disorder] tablet 50 mg .give 50 mg by mouth in the evening related to unspecified psychosis not due to a substance or known physiological condition M/B verbal aggression as evidenced by screaming at others . The MAR indicated on 4/15/22 Resident 150 had new orders for, .quetiapine 50mg, give 50 mg by mouth two times a day related to unspecified psychosis . The DON stated Resident 150's order for Quetiapine was increased from bedtime to two times a day on 4/16/22 due to increased behaviors. The DON stated the MAR indicated Resident 150 had 27 episodes of behaviors in February 2022 and 96 episodes of behaviors in March 2022. During a concurrent interview and record review on 7/13/22, at 10:12 a.m. with RN 1 and the DON, the facility's document titled Side Effects Monthly Flow Sheet, undated was reviewed. RN 1 stated she was aware of the black box warning for the use of Quetiapine which could cause an increased mortality in residents with dementia related psychosis. RN 1 stated she did not know all the resident specific interventions for each resident, so she must look in each resident's care plans to see which interventions to implement then she documented the implemented interventions and effectiveness. The DON stated the nonpharmacological interventions implemented for Resident 150 included change position, give fluids, give food, and redirect. RN 1 stated there were no resident specific interventions documented for Resident 150. RN 1 stated it was important to document interventions implemented because they gave resident specific care, and it shows improvement of behaviors which helps reduce the use of antipsychotic medications. The DON stated the Side Effects Monthly Flow Sheet indicated Resident 150 did not have resident specific nonpharmacological interventions. The DON stated it was important to document resident specific nonpharmacological interventions because Resident 150 had increased behaviors which resulted in the physician increasing the frequency of Quetiapine, when her increased behaviors could have been due to adjusting to her new environment. The DON stated her expectations were for LN to document nonpharmacological interventions when they are implemented. During an interview on 7/14/22, at 1:10 p.m., with PHY 1, PHY 1 stated he was aware of the black box warning related to dementia related psychosis but Resident 47's behaviors warranted antipsychotic medications. PHY 1 stated he based his decisions on the nurses report to him of Resident 47's behaviors. PHY 1 stated his expectations were for nurses to implement nonpharmacological interventions prior to him implementing pharmacological interventions. PHY 1 stated Resident 47 could be re-directed several times, but re-direction was no longer working for Resident 47. During an interview on 7/14/22, at 3:45 p.m. with the CP, the CP stated resident specific nonpharmacological interventions should be implemented and documented to assess the effectiveness of interventions. During a review of the facility's P&P titled, Psychoactive Drug Monitoring, undated, the P&P indicated, Nonpharmacological interventions, such as behavior modification or social services and their effects, are documented as a part of the care planning process, and are utilized by the prescriber in assessing the continued need for psychoactive medication .all of the following conditions are satisfied prior to initiation and/or continuation of therapy: .the need for response to therapy is monitored and documented in the resident's medical record .documentation that the resident is being monitored for adverse consequences or complications of therapy .documentation that a resident's decline or deterioration is evaluated by the interdisciplinary team to determine that the regimen in question is not the cause .the consultant pharmacist compiles, analyzes, and presents data related to psychoactive drug use in the facility .anti-psychotics are given only if the resident has been diagnosed with one of the following indications, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) .the diagnosis is documented in the medical record, or .for a diagnosis .acute psychotic episodes, brief reactive psychosis .dementia, delirium .and other cognitive disorders with associated psychotic and/or agitated behaviors .Residents receive anti-psychotic medication only for behaviors that are quantitatively and objectively documented through the use of behavioral monitoring charts or a similar mechanism. Residents receive anti-psychotic medication only for behaviors that are persistent, that are not caused by preventable reasons, and are causing the resident to: present a danger to self or others .continuously scream, yell, or pace .experience psychotic symptoms (such as hallucinations, paranoia, and delusions) .