**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure accurate documentation of a mental health diagnosis for 1 of 28 sampled residents (Resident 75) based on standards of practice when Resident 75's medical record was marked with schizoaffective disorder (a mental health disorder marked by a major mood episode and a break down between thought, emotion, and behavior) as a diagnosis for use of quetiapine (brand name used- an antipsychotic [mind altering] medication used to treat mental disease) and aripiprazole (brand name used, antipsychotic) with no prior history of such diagnosis. This failure resulted in Resident 75 being inappropriately administered aripiprazole and quetiapine, which resulted in adverse events including weight gain. Findings: During an observation on 6/5/24 4:36 p.m., in Resident 75's room, Resident 75 was observed lying on right side in his bed watching television. When asked how he was doing, Resident 75 responded, by pointing to his ears and stating he couldn't hear too good in a loud voice. During a review of Resident 75's Hospital Medical Records (HMR) dated, 11/19/22, the HMR indicated, History of Present Illness . Per son, patient has underlying memory issues but has not had formal evaluation . Assessment: Per [son], their father lives alone though they tried to convince him to live with them but pt [patient] preferred to live by himself . Principal Diagnosis Cerebellar CVA [cerebral vascular accident happens when blood supply stops to the part of the brain that helps with body movement, eye movement, and balance] . Active Problem List . ataxia [loss of coordination] . During a review of Resident 75's Face Sheet (FS a document containing resident's personal information), dated 6/7/24, Resident 75's FS indicated, Resident 75 was admitted to the facility on [DATE] with diagnoses including ataxia following cerebral infarction, (CVA) and cerebellar stroke syndrome (CVA in certain area of the brain). During an interview on 6/6/24 at 10:38 a.m., with Resident 75's Responsible Party (RP) 2, RP 2 stated he was previously told his father, Resident 75, had dementia. RP 2 stated that the facility however, told him that Resident 75 had Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and may seem like they have lost touch with reality), that is why Resident 75 was being administered medication. RP 2 stated he thought it was dementia because people like Resident 75 didn't have short term memory but had long term memory. RP 2 stated, I guess they were having problems with him, he would get angry, and he wouldn't let them help him, they said it wouldn't harm him, it would help him be calm, it was last year or year before, I'm not sure. RP 2 stated, Resident 75 slept a lot more and didn't want to eat. RP 2 stated, He was always active then all of sudden he started getting tired, not wanting to get up and sleeping a lot and the food too, not wanting to eat I think started happening last year. RP 2 stated he has had to go to the facility to talk to Resident 75 and get him to understand the facility is there to help him and shared with the facility to tell Resident 75 that everything is all right, they're his friends and they're there to help him and he's safe. During a review of Resident 75's Minimum Data Set (MDS) (assessment and care screening of a patient) dated 12/1/22, 2/28/23, and 5/30/23, Resident 75's MDS indicated Resident 75 did not have a diagnosis for psychiatric or mood disorder including bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows) or schizophrenia, and Resident 75 did not have a history of hallucinations (when one thinks something they see, hear, smell, touch or taste is real, but it's not or delusions (inability to distinguish what is real and what seems to be real). During a review of Resident 75's Physician Orders (PO) and Medication Administration Record (MAR ) dated 2/23, 5/23, 6/23, 7/23, 8/23 2/24, 3/24, for aripiprazole, Resident 75's PO and MAR indicated for: Aripiprazole 2 mg (milligram unit of measure) daily for bipolar disorder manifested by slamming door shut, barricading door and jumping on bed 3/4/23 to 3/9/23 Aripiprazole 2 mg twice daily for bipolar disorder manifested by slamming door shut, barricading door, and jumping on bed 3/9/23 to 5/9/23 Aripiprazole 5 mg daily for schizoaffective disorder 6/29/23 to 7/13/23 Aripiprazole 5 mg twice daily for schizoaffective disorder 7/13/23 to 10/24/23 Aripiprazole 2 mg twice daily for schizoaffective disorder 10/24/3 to 5/6/24 Aripiprazole 2 mg daily for schizoaffective disorder 5/6/24 to 5/22/24 Aripiprazole 2 mg every other day for 5 days for schizoaffective disorder 5/22/24 to 5/27/24 During a review of Resident 75's PO and MAR for Quetiapine, Resident PO and MAR dated 2/23, 5/23, 6/23, 7/23, 8/23 2/24, 3/24, for quetiapine, Resident 75's PO and MAR indicated for: Quetiapine 50 mg every 12 hours for schizoaffective disorder manifested by pacing down the hallways and yelling I own this building, I run this place and trying to hit everyone 5/4/23 to 7/11/23 Quetiapine 100 mg every 12 hours for schizoaffective disorder 7/11/23 to 10/24/23 Quetiapine 75 mg by mouth every 12 hours for schizoaffective disorder 10/23/23 to 2/6/24 Quetiapine 50 mg by mouth every 12 hours for schizoaffective disorder 2/6/24 to 5/6/24 Quetiapine 25 mg every 12 hours for schizoaffective disorder 5/6/24 to 5/30/24 Quetiapine 12.5 mg at bedtime for schizoaffective disorder 5/30/24 to present During an interview on 6/6/24 at 2:53 p.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated she had cared for Resident 75 for on and off for almost 2 years. CNA 8 stated when Resident 75 was first admitted on [DATE], he was more alert, would get into his wheelchair, go to the dining room; Resident 75 didn't have as many falls and ate a lot better. CNA 8 stated she observed a big change in Resident 75 after he experienced COVID 19 (highly contagious respiratory disease cause by coronavirus) positive symptoms (December 2023); Resident 75 stopped eating for a little bit, and wanted to lay down, not wanting to get up or go to dining room. CNA 8 stated, she did not notice Resident 75 to have hallucination or delusions during her care. CNA 8 stated Resident 75 would look at staff confused and ask why everybody was in his house, say he wanted everybody out of his house, and ask for his family. During a review of Resident 75's Nursing Progress Notes (NPN), Resident 75's NPN indicated on: 11/29/22 12:14 p.m. Resident new admit. Resident alert and oriented x [for] 3 [measure for alertness and orientation]. Resident refused to get VS [vital signs medical signs that indicate the status of the body's vital functions] @ [at] 1100. Resident is non compliant and stated he is going to get up and walk home. Redirected resident to stay and get the help that he needs. Resident appears to not want to be here. Will cont. [continue] to monitor. 12/1/22 4:23 p.m. Writer was in room with resident and resident states they want to kill themselves, life is not living anymore and talks about past friend who killed themselves. CNA was also present and writer counted that resident repeated taking own life seven times approximately every other minute. Writer tried to talk to resident but resident is hard of hearing and does not comprehending. Resident kept going back to story of friend taking their own life and then resident states about taking own life. Writer inform DSD [Director of Staff Development], DON [Director of Nursing], Nurse and dinning services. Resident has one on one and on plastic utensils for 72 hours. 12/29/22 12:20 p.m. Resident is in bed watching the rain outside his window while having lunch. He is in a cheerful mood. Bed is in the lowest position along with call light/ bed control in his reach. He is telling the nursing team fond memories of his dog in the rain. His son did visit and will try to bring a photo the next time he visits him. 1/2/23 6:26 a.m. Resident is in a happy mood. A sign has been placed at his door to inform him that his son has his dog. He does enjoy talking to the noc [overnight] nursing team about life and his fond family memories. 1/20/23 10:50 a.m. Resident is S/P [status post after] room change to [room number]. He is adjusting well to his new room. He is in bed looking out the window and watching his tv. The bed is in the lowest position along with his bed controls being in his reach. He reports no pain or discomforts at this time. 1/21/23 10:56 a.m. Resident is S/P room change to [room number] He is adjusting well to his new room. He is in bed looking out the window and watching his tv. The bed is in the lowest position along with his bed controls being in his reach. He reports no pain or discomforts at this time. He keeps asking about his dog and is redirected by the staff. 1/24/23 3:22 p.m. Resident is S/P room change. He is adjusting well to room change. He has his call light and bed controls in his reach with his bed in the lowest position. He is in in his bed. 2/2/23 2:42 a.m. Writer observed resident resident getting into his roommates face telling him to get out of his room. Resident was educated on personal space and sharing the room. 2/2/23 4:57 a.m. Resident is upset to have another person in his room. He stated to the nursing team that he pays for this room and want to be alone in it. Writer educated the resident on the sharing of the room. He is upset and demanding that the other resident be moved out now. 2/13/23 9:59 p.m. Resident would mostly yell when he is hungry then shuts his door loudly which made another resident upset with the loud noise. He would also close the bathroom door so loud and his door closet. When resident is told about not shutting the doors, resident yells back at staff. 2/17/23 3:59 a.m. Resident continues to come out of room and ask about his dog and slam the room door. He reports his pain to be 0\10 with no discomforts. He has been offered several snacks and is now in his room watching the tv. 2/19/23 8:10 a.m. Writer along with the CNA staff have offered x3 to help the the resident change his clothing and to take a bed bath. He has refused x3 [three times] and yelled at the staff to get the hell out of his room now. Writer encouraged the resident to use a lower tone and to use his call light if he is in need of aid. 2/19/23 12:23 p.m. Resident is in bed having his lunch. He reports no pain or discomfort at this time. Bed is in the lowest position with call light and bed controls in his reach. Resident is able to make his needs known to the nursing team. He has been ambulating in the facility with ease with his non skid foot wear. He went outside with he writer to get some fresh air and look at he trees . He got excited when he saw all of the cars driving by. Call light and bed controls are in his reach. resident was offered aid to change his clothing he refused x3 again. 2/21/23 2:16 a.m. Resident is in his wheel chair looking for his dog at this time. He has been offered snack which he has eaten. He reports his pain to be none with no discomfort/ distress at this time. Writer did encourage him to wear non skid foot wear and to use the call light for aid. Writer did offer to help the resident change his clothing. Resident refused x 3. 2/25/23 11:59 a.m. Resident is on charting for s/p fall, no delayed injuries noted. Resident is alert. No new skin issues noted. Resident is in bed watching the tv and calling out for his dog. His call light/ bed control are within reach. He is s/p room change and is adjusting well to this new room. His son [RP 2] came to visit today. he was upset that he was not notified of his father being moved to another room. He informed the writer that the communication between the facility and family needs to greatly improve. Writer informed RP that this matter would be brought to the social service attention. 2/28/23 1:15 a.m. Resident is up opening his screen door yelling. Writer informed the resident that his dog was gone with his son. He was asked about pain he said no pain. Resident was given a snack. He is now in bed watching the tv. He was reminded to wear non skid footwear and to use his call light for aid. 3/2/23 6:11 a.m. Resident is up opening his screen door yelling out for his dog. Writer informed the resident that his dog was gone with his son. He was asked about pain he said no pain. Resident was given a snack. He is now in bed watching the tv. He was reminded to wear non skid footwear and to use his call light for aid. 3/3/23 2:02 a.m. Upon the NOC med pass. Writer was informed by the CNA on the wing of the resident slamming the restroom door in her face and striking her on the left shoulder. Writer asked the resident what was going on. He stated to the writer why is he in my bathroom? I pay rent here. Get him out of my house. Writer informed the reside that they all live here together. Along with sharing this space in the restroom. A snack was offered. Resident was helped back to his bed. Call light is in reach. Bed is in the lowest position. Writer asked resident if he was having any pain or discomfort. He replied no I'm fine just get him out of here. CNA did fill out an incident report. Writer did encourage he resident to keep his hands to himself. 3/3/23 2:13 p.m. Resident is being aggressive and getting into residents faces for being in common areas such as the hall way and restroom. He is not easily redirected until he feels as if he is getting his point across. He has been reminded of personal space and to keep his hands to himself and off others. resident was asked if he was in pain or having discomforts he responded with no I'm fine. Writer has placed his bed in the lowest position with the wheels being locked. A tv program of his choice is also playing. Resident is in a happy mood at this time. 3/4/23 3:14 a.m. Resident is being aggressive and getting into other residents/ staff faces for being in common areas such as the hallway and restroom. He is not easily redirected. He has been reminded of personal space and to keep his hands to himself and off others. Writer asked the resident was asked if he was in pain or having discomforts he responded with no. Writer is walking with the resident in the facility and looking outside with him to calm him talking about dogs and the war. Writer has placed his bed in the lowest position with the wheels being locked. A tv program of his choice is also playing. Resident is content and in bed. 3/4/23 3:20 p.m. Resident has a new order for [Brand name] Oral Tablet 2 MG (Aripiprazole) for Bipolar Disorder. Resident has been put on the medication due to behaviors. Resident MD [doctor] was contacted and was described the resident's behaviors and manifestations. Resident has such Manifestations Slamming Door Shut, Barricading door and Jumping on bed and has visual Hallucinations of seeing a dog and other humans. Resident MD gave the orders for this medications along with a DX [diagnosis] of Bipolar Disorder to support the medication order. Resident is self RP and aware of this new order of the medication. 3/5/23 00:11 a.m. Upon writers rounds the resident was in the hallway yelling for his dog. Writer informed the resident that his dog was with his son and that people are trying to sleep. Resident informed the writer that he don't care we are all nuts. Writer informed the resident that he was safe and being cared for. The resident was asked if he was in pain or having discomforts he responded with no. Writer has placed his bed in the lowest position with the wheels being locked. A tv program of his choice is on. Writer offered the resident a snack. He told writer thank you and sat on his bed. 6/23/23 2:06 a.m. Resident is up walking he halls of the wing. Going into other rooms demanding that the resident get the [expletive] out of his house or his sister will kick their ass. Writer informed the resident of personal space and using respectful language when talking to others. Resident has been redirected to the common areas of the facility. When asked about his pain he reports that he is fine and we need to get out of his house. Resident is in the common room watching the tv and having snacks. 6/26/23 2:06 a.m. Resident is up walking [the] halls of B wing. Going into the other rooms looking for his dog and questioning why all these people are here? He is demanding that we all leave his [expletive] trailer. Writer informed the resident of personal space and using respectful language when talking to others. Resident has been redirected to the common areas of the facility. When asked about his pain he reports that he is ok. Resident is in the common room watching the tv with other residents and having snacks. He has on his non skid footwear. His bed is in the lowest position with his call light in reach. 6/26/23 1:03 p.m. The resident is being aggressive and keeps wanting to leave the facility. Keeps asking bankruptcy and how it will effect his life. The writer redirected the resident he is in the facility at this time for rehab. Snacks and coffee was provided and offered him to join the other residents for coffee social. Resident is enjoying coffee in the dining room with other residents and is watching Tv. He is relaxed and calm. During a concurrent interview and record review on 6/6/24 at 3:22 p.m., with MDS Nurse (MDSN) 1, Resident 75's Preadmission Screening and Resident Review (PASRR federal regulation that requires all individual being considered for admission to a Medicaid certified nursing facility be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition) dated 11/29/22, Resident 75's PASRR was reviewed. Resident 75's PASRR indicated, . no serious mental illness . result of level I screening . negative. MDSN 1 acknowledged Resident 75's PASRR was conducted upon admission to the facility. During a telephone interview on 6/6/24 at 3:34 p.m., with Psychologist (PSYCH), when asked about Resident 75's diagnosis of schizoaffective disorder, PSYCH stated he did not have a copy of the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 (handbook that contains criteria for diagnosing mental disorders and is used by healthcare professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders) to review the criteria for diagnosis, and his best guess was that he carried the diagnosis forward and did not make the diagnosis. During a concurrent telephone interview and record review on 6/6/24 at 4:15 p.m., with Physician (PHY) 1, PHY 1 stated Resident 75 had diagnoses including dementia, hearing loss, post CVA and hypertension. When asked why Resident 75's diagnosis of dementia was not updated on Resident 75's electronic medical record or Minimum Data Set (MDS -a standardized comprehensive assessment and care planning tool), PHY 1 stated, If you look at my notes, I mentioned it a few times, its what the clinicians see, it should be there some place. PHY 1 stated he did not diagnose Resident 75 with schizoaffective disorder, and that it came from a psychiatrist. During a review of Resident 75's Nursing Progress Note (NPN) dated 5/24/23, Resident 75's NPN indicated, Writer contacted [Physician] by phone to notify him of the resident recent behaviors of getting into other residents' personal space, making threats and his non sleeping pattern. MD [PHY 1] gave new medication orders. MD gave orders for [Quetiapine brand name] 50 mg every 12 hours. MD was asked what diagnosis MD would like to give for this medication. MD stated schizoaffective disorder. PHY 1 stated he gave the schizoaffective disorder diagnosis and that with schizophrenia, there was no chemical test. PHY 1 stated he had to use something else to justify putting Resident 75 on those medications. When asked why Resident 75 concurrently on aripiprazole and quetiapine, PHY 1 stated that was bad practice and he didn't think he would put Resident 75 on two antipsychotics at the same time. PHY 1 stated he doubted he authenticated the orders and would increase the dose of one, and not both. PHY 1 stated side effects would include falls, and requested the orders be sent to him. PHY 1 stated Resident 75 was on hospice (program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease), and he didn't ask for hospice and didn't know why Resident 75 was on hospice. During a review of DSM 5 criteria for schizoaffective disorder, the DSM 5 criteria indicated, Criterion A (an uninterrupted period of illness during which there is a major mood episode [depressive or manic] concurrent with Criterion A1 [at least 2 of the following, each present for a significant portion of time during a 1 month period [or less if successfully treated]. At least 1 of these must be 1, 2, or 3: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior [lack of movement and communication] 5. Negative symptoms [diminished emotional expression]); Criterion B (delusions or hallucinations for at least 2 weeks in the absence of a major mood episode [depressive or manic] during the lifetime duration of the illness); Criterion C (symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness); Criterion D (the disturbance is not attributable to the effects of a substance or another medical condition). During an interview on 6/6/24 on 4:29 p.m., with MDSN 1, MDSN 1 was unable to provide a PASRR for Resident 75 upon initiation of aripiprazole for a mental illness. MDSN 1 stated a PASRR should have been completed when Resident 75 was given a new psychiatric diagnosis. MDSN 1 stated it was important to ensure that the facility was still the appropriate place for the resident to be. During an interview on 6/7/24 at 9:36 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 75 was moved to a private room to give him a change of scenery because it was difficult for him to have a roommate. Resident 75 would get agitated a lot and behaviors were escalating when he tried to jump over the fence and become physically aggressive. LVN 3 stated Resident 75 did better in the private room, and she (LVN 3) did not observe some of the behaviors that was said to have been happening in the other wing. LVN 3 stated Resident 75 often asked to go home. LVN 3 stated she was unaware why Resident 75 was moved to a room with another resident. During a review of Resident 75's Physician Progress Notes (PPN), dated 2/19/23 and 3/19/23, the PPN dated 2/19/23 indicated, Dementia suspected and the PPN dated 3/19/23 indicated, Dementia. During a concurrent interview and record review on 6/7/24 at 10:09 a.m., with LVN 3, Resident 75's FS dated 6/7/24 and HMR dated 11/19/22 were reviewed. LVN 3 was unable to provide documentation of Resident 75's diagnosis of dementia among Resident 75's list of diagnoses. LVN 3 stated that for symptoms like forgetfulness, the psychiatrist came in and evaluated resident. LVN 3 acknowledged Resident 75 was forgetful. LVN 3 acknowledged Resident 75's HMR indicated Resident 75 had underlying memory issues. LVN 3 acknowledged Resident 75's concurrent orders for antipsychotic medications quetiapine and aripiprazole. When asked about an evaluation or assessment from a physician or mental health provider for diagnosing Resident 75's with schizoaffective and bipolar disorders, LVN 3 was unable to provide documentation. LVN 3 stated she or the CNAs that worked during her shift had not observed Resident 75 experiencing hallucinations, however Resident 75 had been observed to be forgetful, confused and agitated. During a concurrent telephone interview and record review on 6/7/24 at 3 p.m., with Registered Dietician (RD) 2, Resident 75's Weights and Vitals Summary Log (WVSL) dated 11/1/22 to 6/30/24 and Dietician Progress Notes (DPN) dated 12/29/22, 4/4/23, 6/9/23, 7/7/23, and 10/2/23 were reviewed. Resident 75's weight log indicated, 12/7/22 111 lbs [pounds], 2/13/23 115 lbs, 3/2/23 122 lbs, 4/4/23 125 lbs, 5/1/23 126 lbs, 6/5/23 132 lbs, 7/4/23 135 lbs, 8/1/23 140 lbs, 9/4/23 139 lbs, 10/2/23 143 lbs, 11/6/23 145 lbs, 12/1/23 144 lbs, 1/2/24 143 lbs, 2/13/24 113 lbs, 3/1/24 114 lbs, 4/1/24 106 lbs, 5/4/24 104 lbs 6/2/24 108 lbs. RD 2 acknowledged Resident 75's weight gain and stated Resident 75's ideal body weight was 106 to 130, body max index (BMI indicates high body fat and screens for weight categories that may lead to health problems). A review of Resident 75's DPN dated 12/29/22 indicated, 4 lb weight gain since admission weight 12/7 [2022]111 lbs BMI: 4 normal . consuming 75 100% of meals. Good appetite noted attributing to weight gain. A review of Resident 75's DPN dated 4/4/23 indicated, 125 lb, non significant weight gain x [in] 1 month (3/2: 122 lbs) and significant 8.7% 10 lb weight gain x 3 months (1/4: 115 lb) BMI: 22.9 normal. Weight gain was desired. On house supplement TID [three times daily] attributing to weight gain. Social Services/Activities: On [Aripiprazole brand name] for bipolar which may cause weight gain . Recommend to reduce to 120 ml [milliliters] at dinner . A review of Resident 75's DPN dated 6/9/23 indicated, CBW [current body weight] 132 lbs 6/5, 4.8% 6 lb weight gain x 1 month (5/1 126 lbs, significant 8.2% 10 lbs weight gain x 3 months (3/2 122 lbs), significant 18.9% 21 lb weight gain x 6 month (12/7 111 lbs). BMI 24.1 normal. Weight gain desirable. Nursing: On [Quetiapine brand name] can contribute to weight gain. A review of Resident 75's DPN dated 7/7/23 indicated, CBW 135 lbs 7/4, 3 lb wt [weight] gain x 1 month (6/5 132 lbs), significant 8% 10 lb wt gain x 3 months (4/4 125 lbs), significant 17.4% 20 lb wt gain x 6 months (1/4 115 lbs). BMI 24.7 normal Previously discontinued house supplement last month in IDT [Interdisciplinary Team group of healthcare professionals from different fields working together to determine a patient's treatment plan] wt variance d/t [due to] adequate oral intake. Nursing: On [Quetiapine brand name]; potentially contributing to wt gain. Lipid panel and A1c [blood test about level of blood sugar over period of time] ordered by MD for this month. A1c 6.6% . MD advised to just watch his diet. A review of Resident 75's DPN dated 10/3/23 indicated, Value [weight] 143. Resident previously reviewed by IDT for significant wt change. Stable wt trend x 4 months. IDT to remain available and monitor on monthly weights. A review of Resident 75's DPN dated 11/6/23 indicated, CBW 145 lbs 11/6, wt gain x1 month (10/2 143 lbs), 5 lb wt gain x 3 months (8/1 140 lbs), significant 15.1% 19 lb wt gain x 6 months (5/1 126 lbs). BMI 26.5 overweight status . No additional supplements provided. RD 2 stated Resident 75 had a weight alert due to a significant weight gain during a six month period. RD 2 stated he was part of the IDT meetings and they looked at different medications such as antipsychotics that could cause weight gain. RD 2 stated, he did not see any indication in Resident 75's medical record that would indicate fluid retention due to medications or diagnosis. RD 2 stated he was aware antipsychotic medication could cause weight gain. RD 2 stated for patient on medications, he may speak to the physician to determine if there was a different medication the resident can try, and the physician could order a more beneficial medication for the resident without the weight gain. During a concurrent interview and record review on 6/10/24 at 8:31 a.m., with Minimum Data Set Nurse (MDSN), MDSN stated she was not aware Resident 75 had a diagnosis of dementia. MDSN stated if Resident 75's physician diagnosed Resident 75 with dementia, it should be added that same day into Resident 75's profile because that would be the day the diagnosis became active. MDSN stated MDS staff is expected to review Resident 75's chart and input any new diagnosis. MDSN stated this was important because it could affect Resident 75's care; if all of staff is not aware Resident 75 has dementia, they might not know how to approach him or that he needs a different kind of approach. During a concurrent interview and record review on 6/10/24 at 8:41 a.m., with Administrator in Training (AIT), Resident 75's PO for aripiprazole and quetiapine were reviewed. AIT acknowledged being the assistant director of nursing at that time and confirming an order for quetiapine 50 mg every 12 hours for schizoaffective disorder on 5/4/23. AIT stated Resident 75 was having behaviors and told a nursing staff to call PHY 1 and asked PHY 1 what diagnosis to put for Resident 75's order for quetiapine. AIT also acknowledged confirming all of Resident 75's quetiapine and aripiprazole orders including aripiprazole 2 mg by mouth once daily for bipolar disorder manifested by slamming door shut, barricading door, and jumping on bed, on 3/4/23 with PHY 1 and aripiprazole 5 mg by mouth once daily for schizoaffective disorder on 6/28/23. AIT stated he was aware that quetiapine and aripiprazole were both antipsychotic medications and acknowledged Resident 75 was concurrently administered both quetiapine and aripiprazole. AIT stated he presented all the information to PHY 1 and told PHY 1 all the medications Resident 75 was being administered and that was what PHY 1 gave the nursing staff. AIT stated, [Resident 75] was so unmanageable on our end]. AIT stated he did not remember Resident 75 having dementia and was aware some medications had black box warnings (highest safety related warning that medications can have assigned by the Food and Drug Administration, a federal government agency). During a telephone interview on 6/10/24 at 9:03 a.m., with Consultant Pharmacist (CRPH), CRPH acknowledged Resident 75 was administered aripiprazole twice daily. CRPH stated aripiprazole is usually given once daily because it is long acting. CRPH stated if aripiprazole was given twice daily, it would have more side effects and had not seen it used twice daily. CRPH stated if ordered twice daily, the expectation would be to ask the physician and confirm the order. CRPH stated concurrent administration of quetiapine and aripiprazole was not appropriate and the expectation would be to inform the physician because of increase side effects and therapy duplication. CRPH acknowledged antipsychotics can cause weight gain and stated weight gain was one of the major side effects of quetiapine. CRPH stated the expectation would be to ask the physician to gradually reduce the medication dosage to treat the resident's condition and lower the risk of side effect. CRPH stated the higher the dose, the higher the risk of side effect. CRPH stated doing a medication review to see if other medication that could cause weight gain and switching to other psychotropic medications that do not cause weight gain would also be an alternative. CRPH stated antipsychotics have a risk to increase blood sugars and fats. CRPH stated Resident 75 was not on any dementia medication and she was not aware Resident 75 had a diagnosis of dementia. During a telephone interview on 6/10/24 at 10:15 a.m., with Medical Director (MD), MD stated when there was a new diagnosis, facility is expected to update the resident's care plan. During an[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive assistive devices to maintain hearing abilities for one of 28 sampled resident (Resident 75) when Resident 75 who was extremely hard of hearing, was assessed for the use of hearing aid, and was not provided with hearing aid. This failure resulted in Resident 75 not having hearing aid to maintain hearing for communication with staff regarding care needs and treatment, and compromise Resident 75's quality of life. Findings: During an observation on 6/5/24 at 4:36 p.m., in Resident 75's room, Resident 75 was observed lying on right side in his bed watching television. When asked how he was doing, Resident 75 responded, by pointing to his ears and stating he couldn't hear too good in a loud voice. During a review of Resident 75's Hospital Medical Records (HMR) dated, 11/19/22, the HMR indicated Resident 75 was an [AGE] year old male who was extremely hard of hearing. The HMR also indicated during a physical examination, Resident 75 was wearing a hearing aid in right ear. During a review of Resident 75's Face Sheet (FS - a document containing resident's personal information), dated 6/7/24 indicated, Resident 75's FS indicated Resident 75 was admitted to the facility on [DATE] with diagnoses including unspecified hearing loss, unspecified ear. During an interview on 6/6/24 at 2:36 p.m., with Certified Nursing Assistant (CNA) 8, CNA 8 stated Resident 75 was hard of hearing and if someone wanted to speak with him, they had to get close and speak in his ear. CNA 8 stated Resident 75 did not like staff getting close to him, so staff used their hands a lot. CNA 8 stated she did not know Resident 75 used hearing aids and had never seen him wear a hearing aid. During a review of Resident 75's Nursing Progress Notes (NPN), dated 11/29/22 at 12:14 p.m., the NPN indicated, Resident new admit. Resident alert and oriented x [for] 3 [measure for alertness and orientation]. Resident refused to get VS [vital signs medical signs that indicate the status of the body's vital functions] @ [at] 1100. Resident is non compliant and stated he is going to get up and walk home. Redirected resident to stay and get the help that he needs. Resident appears to not want to be here. Will cont. [continue] to monitor. During a review of Resident 75's Nursing Progress Notes (NPN), dated 12/1/22 at 4:23 p.m., the NPN indicated, .Writer tried to talk to resident but resident is hard of hearing and does not comprehending . During a concurrent record review and interview on 6/6/24 at 4:39 p.m., with the Social Services Director (SSD), the SSD was unable to provide facility documentation of Resident 75 using hearing aids. The SSD stated Resident 75 had never had hearing aid at the facility. SSD stated upon admission on [DATE], the facility should have done a social service evaluation to include an assessment for hearing aids. The SSD stated the social service evaluation was not completed and Resident 75's need for a hearing aid was not assessed upon admission to the facility. During an interview on 6/7/24 at 9:50 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated staff had to speak to Resident 75 loudly when communicating. LVN 3 stated Resident 75 got agitated when asked to do activities of daily living, however Resident 75 would not go out of his way to have an altercation. LVN 3 stated Resident 75 did not have a communication board in his room. LVN 3 stated if Resident 75 was admitted to the facility and documents from other facility stated Resident 75 had hearing aids, upon admission, staff should have ensured Resident 75 had hearing aids, check Resident 75's belongings, and monitor Resident 75 to ensure hearing aids were put in daily. LVN 3 stated if the hearing aids were not in Resident 75's belongings upon admission to the facility, staff should have called the previous facility or hospital and asked the Responsible Party (RP) 2 to get clarification to see if hearing aids were lost or the information had changed. During an interview on 6/10/24 at 10:20 a.m., with Medical Director (MD), MD stated social services and nursing staff should have identified Resident 75 was using a hearing aid and should have assessed Resident 75 and developed a care plan for it. MD stated not assessing or care planning for Resident 75 could have impacted social activities, meals, and interaction with people, and could have led to isolation, and depression. During a concurrent interview and record review on 6/10/24 at 1:22 p.m., with Director of Nursing (DON), DON was unable to provide documentation of Resident 75's care plan for hearing aid and stated she was unaware Resident 75 used hearing aid. DON stated, I didn't see any when he came. DON stated hearing aid was important for Resident 75's daily routine care and if Resident 75 was hard of hearing, he could have misunderstood words.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that one of nine sampled residents (Resident 75) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when: 1. The facility did not attempt or implement resident specific non pharmacological interventions (behavioral intervention not based on medicine) prior to prescribing and administration of alprazolam (an antianxiety medication), Resident 75 was administered alprazolam unnecessarily. 2. The facility did not provide documented clinical rationale for administrating and increasing the dosage of aripiprazole (an antipsychotic mild altering drug to treat mental illness) and quetiapine (antipsychotic medication), and Resident 75 was administered aripiprazole and quetiapine unnecessarily. 3. The facility did not attempt or implement resident specific non pharmacological interventions prior to prescribing and administration of escitalopram (antidepressant medication), and Resident 75 was administered inappropriate dosage of escitalopram. These failures resulted in Resident 75 experiencing falls, weight gain, dysphagia (difficulty swallowing) and increased the potential for Resident 75 to be isolated. Findings: 1. During a review of Resident 75's Hospital Medical Records (HMR) dated, 11/19/22, the HMR indicated, History of Present Illness . Per son, patient [Resident 75] has underlying memory issues but has not had formal evaluation . Assessment: Per [son], their father [Resident 75] lives alone though they tried to convince him to live with them but pt [patient] preferred to live by himself . Principal Diagnosis Cerebellar CVA [cerebral vascular accident happens when blood supply stops to the part of the brain that helps with body movement, eye movement, and balance] . Active Problem List . ataxia [loss of coordination] . During a review of Resident 75's Face Sheet (FS- a document containing resident's personal information), dated 6/7/24, Resident 75's FS indicated, Resident 75, was an [AGE] year old male who was admitted to the facility on [DATE] with diagnoses including ataxia following cerebral infarction, (CVA) and cerebellar stroke syndrome (CVA affecting a certain part of the brain). During an interview on 6/6/24 at 10:38 a.m., with Resident 75's Responsible Party (RP) 2, RP 2 stated he has had to help Resident 75 to keep his balance. RP 2 stated Resident 75 was pretty good, able to walk on his own and noticed Resident 75 couldn't keep his balance after the falls. During a concurrent interview and record review on 6/7/24 at 11:28 a.m., with (Licensed Vocational Nurse (LVN) 3, Resident 75's Physician Orders (PO), Medication Administration Record (MAR) for alprazolam and Nursing Progress Notes (NPN) were reviewed. Resident 75's PO and MAR indicated: Alprazolam 0.5 mg (milligrams unit of measure) by mouth every 12 hours for anxiety manifested by feeling panicky and getting in other residents and staffs' face while being around others 2/16/23 to 2/20/23 (order date to discontinue date) Alprazolam 1 mg by mouth every 12 hours for anxiety for feeling anxious manifested by feeling panicky and getting in other residents and staffs' faces while being around others 2/20/23 to 2/21/23 Alprazolam 0.5 mg by mouth every 12 hours for anxiety for feeling anxious manifested by feeling panicky and getting in other residents and staffs' faces while being around others 2/21/23 to 3/14/23 The review of Resident 75's NPN included: 2/20/23 12:43 a.m. At 1200 [a.m.] writer was called to resident's room by CNA [unknown], when writer entered the room resident was seen on the floor attempting to get himself back up. Resident was screaming at staff stating he wanted to go the restroom, but writer asked resident to be patient so that he may be assessed for any injuries. Writer then assessed resident for pain and resident reported a pain level of 0/10 [scale to measure pain, with 0 being least pain, 10 being most pain]. Head to toe assessment was performed, no superficial injuries noted. Resident refused to allow staff to use mechanical lift [device used to transfer a patient] to pick him up off the floor. Despite efforts of education and encouragement by staff resident stood up on his own and was then assisted to his wheelchair. Resident was then assisted to the restroom by CNA. [Phyician [PHY] 1] was notified via in person @ [at] 1225, gave new orders to monitor for delayed injury x [for] 3 days. Writer left a message for Emergency Contact [RP 2] via telephone to call back. LVN 3 acknowledged Resident 75 experienced a fall on 2/19/23, just prior to midnight. LVN 3 stated the facility consultant pharmacist (CRPH) reviewed Resident 75's medication regimen on 2/20/23 and recommended an assessment of Resident 75's alprazolam as the medication could cause dizziness, and confusion. LVN 3 stated Resident 75's alprazolam dose was increased from 0.5 mg every 12 hours to 1 mg every 12 hours from 2/20/23 to 2/21/23 and decreased back to 0.5 mg every 12 hours from 2/21/23 to 3/14/23. LVN 3 acknowledged Resident 75 had received alprazolam 0.5 mg dosing prior to fall and stated, I'm not seeing a decrease in dose. LVN 3 stated alprazolam can cause confusion, dizziness, fatigue, and falls, and acknowledged Resident 75 experienced unsteady coordination following his stroke. LVN 3 acknowledged Resident 75 did not have a fall prior to alprazolam being ordered. During a review of Resident 75's MAR dated 2/1/23 to 2/28/23, Resident 75's MAR indicated Resident 75 was administered alprazolam 1 mg on 2/20/23 at 8 a.m., 8 p.m., 2/21/23 at 8 a.m., alprazolam 0.5 mg on 2/16/23 at 8 p.m., twice daily at 8 a.m. and 8 p.m. on 2/17/23, 2/18/23, 2/19/23, 2/20/23 at 8 a.m., 2/21/23 at 8 p.m., and twice daily at 8 a.m. and 8 p.m. from 2/22/23 to 2/28/3. During a concurrent interview and record review on 6/7/24 at 11:44 a.m., with LVN 3, Resident 75's Care Plan (CP) and MAR dated 2/1/23 to 2/28/23 were reviewed. LVN 3 was unable to provide monitoring and implementation of resident specific non pharmacological interventions for Resident 75's behaviors for anxiety prior to initiation of alprazolam. LVN 3 stated, there were lots of side effects from pharmacological (medicine) interventions, and staff should have used the least invasive treatment that was beneficial for Resident 75. During a review of Resident 75's Interim Medication Regimen Review (IMRR), dated 2/21/23, Resident 75's IMRR recommendation for alprazolam indicated, Anxiolytic [alprazolam] medication can cause sedation, respiratory depression, confusion, disorientation, dizziness, skeletal/muscle weakness, visual disturbances, fatigue. Please assess the ongoing need at this time, is a GDR [gradual dose reduction - slowly reduce dose to see if patient condition can be managed on lowest dose possible or if medication can be discontinued] warranted at this time. During a telephone interview on 6/10/24 at 9:12 a.m., with CRPH, CRPH stated Resident 75's alprazolam dose was not appropriate. CRPH stated, for elderly patient, limited to 0.75 mg per day. CRPH stated she would ask why patient was administered medication, inquire if patient had taken it before and inform physician that dose is too high for resident. CRPH stated, benzodiazepines [alprazolam] increase risk of fall, that's what we are always worried about, can cause dizziness, confusion. CRPH stated if a fall occurred, it was important to reassess whether the medication was causing problem and whether it was possible to lower the dose. During a review of Resident 75's CVA Care Plan (CP), dated 12/29/22, Resident 75's CVA CP indicated, [Resident 75] is at risk for . generalized weakness, altered balance/gait . Interventions/tasks . PT [physical therapy- help one move better or help strengthen weakened muscles], OT [occupational therapy- to help one improve ability to participate in daily activities] evaluate and treat as indicated . During a review of Lexicomp, a nationally recognized drug reference, the manufacturer for alprazolam indicated, Dosing: Older Adult Note: Avoid use; may be appropriate for severe generalized anxiety disorder. Immediate release: Oral: Use lower initial doses of 0.25 mg 2 to 3 times daily and titrate slowly . Debilitated [physically weak] patients: Use with caution in debilitated patients; use lower starting dose . Older adult patients: Older adults may be at an increased risk of death with use; risk has been found highest within the first 4 months of use in elderly dementia patients . Fall risk: Use with extreme caution in patients who are at risk of falls; benzodiazepines [anti anxiety drug] have been associated with falls and traumatic injury. 2. During an interview on 6/6/24 at 10:38 a.m., with Resident 75's RP 2, RP 2 stated he was previously told his father, Resident 75, had dementia. RP 2 stated that the facility however, told him that Resident 75 had Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, and may seem like they have lost touch with reality), that is why Resident 75 was being administered medications for his behavior. RP 2 stated he thought it was dementia because people like Resident 75 didn't have short term memory but had long term memory. RP 2 stated, I guess they were having problems with him, he would get angry, and he wouldn't let them help him, they said it wouldn't harm him, it would help him be calm, it was last year or year before, I'm not sure. During an interview on 6/6/24 at 2:53 p.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated she had cared for Resident 75 for on and off for almost 2 years. CNA 8 stated when Resident 75 was first admitted on [DATE], he was more alert, would get into his wheelchair, go to the dining room; Resident 75 didn't have as many falls and ate a lot better. CNA 8 stated, she did not notice Resident 75 to have hallucination or delusions during her care. CNA 8 stated Resident 75 would look at staff confused and ask why everybody was in his house, say he wanted everybody out of his house, and ask for his family. During a review of Resident 75's PO and MAR for aripiprazole, Resident 75's PO and MAR indicated: Aripiprazole 2 mg daily for bipolar disorder manifested by slamming door shut, barricading door and jumping on bed 3/4/23 to 3/9/23 Aripiprazole 2 mg twice daily for bipolar disorder manifested by slamming door shut, barricading door, and jumping on bed 3/9/23 to 5/9/23 Aripiprazole 5 mg daily for schizoaffective (a mental health disorder marked by a major mood episode either manic or depressive that co occurs at the same time with symptoms of schizophrenia) disorder 6/29/23 to 7/13/23 Aripiprazole 5 mg twice daily for schizoaffective disorder 7/13/23 to 10/24/23 Aripiprazole 2 mg twice daily for schizoaffective disorder 10/24/3 to 5/6/24 Aripiprazole 2 mg daily for schizoaffective disorder 5/6/24 to 5/22/24 Aripiprazole 2 mg every other day for 5 days for schizoaffective disorder 5/22/24 to 5/27/24 During a review of Resident 75's PO and MAR for Quetiapine, Resident 75's PO and MAR indicated: Quetiapine 50 mg every 12 hours for schizoaffective disorder manifested by pacing down the hallways and yelling I own this building, I run this place and trying to hit everyone 5/4/23 to 7/11/23 Quetiapine 100 mg every 12 hours for schizoaffective disorder 7/11/23 to 10/24/23 Quetiapine 75 mg by mouth every 12 hours for schizoaffective disorder 10/23/23 to 2/6/24 Quetiapine 50 mg by mouth every 12 hours for schizoaffective disorder 2/6/24 to 5/6/24 Quetiapine 25 mg every 12 hours for schizoaffective disorder 5/6/24 to 5/30/24 Quetiapine 12.5 mg at bedtime for schizoaffective disorder 5/30/24 to present During a review of Resident 75's Nursing Progress Notes (NPN), Resident 75's NPN indicated on: 3/4/23 3:20 p.m. Resident [75] has a new order for [Brand name] Oral Tablet 2 MG (Aripiprazole) for Bipolar Disorder. Resident has been put on the medication due to behaviors. [PHY 1] was contacted and was described the resident's behaviors and manifestations. Resident has such Manifestations Slamming Door Shut, Barricading door and Jumping on bed and has visual Hallucinations of seeing a dog and other humans. [PHY 1] gave the orders for this medications along with a DX [diagnosis] of Bipolar Disorder to support the medication order. Resident is self RP and aware of this new order of the medication. 3/9/23 3:14 p.m. This order is outside of the recommended dose or frequency. [Brand name] Oral Tablet 2 MG (Aripiprazole) Give 1 tablet by mouth two times a day for Bipolar Disorder Manifested by Slamming Door Shut, Barricading door and Jumping on bed The frequency of 2 times per day exceeds the usual frequency of daily. 3/15/23 10:05 a.m. Resident medications have been changed from [Alprazolam brand name] to [Lorazepam brand name] due to medications being ineffective for the resident. Resident RP [2] was notified via phone of the changes and agreed. [PHY 1] gave the orders For [Lorazepam brand name] 0.5 mg every 12 hours. Will Continue to monitor for any side effects or any behaviors. 5/4/23 7:21 a.m. Writer contacted [PHY 1] by phone to notify him of the resident's recent behaviors of getting into other residents personal space, making threats and his non sleeping pattern. [PHY 1] gave new medication orders. [PHY 1] gave orders for [Quetiapine brand name] 50mg every 12 hours. [PHY 1]was asked what diagnosis [PHY 1] would like to give for this medication. [PHY 1] Stated Schizo effective Disorder. 7/10/23 7:49 a.m. Resident was seen by Psychologist [health professional that helps one address mental and behavioral issues] Face Face on 7/7/2023. No New Orders at this time. 7/11/23 1:36 a.m. Writer was informed of the resident going into other residents' room demanding that they leave and get the [expletive] out of his house now before his sister comes and kicks our asses. Writer contacted [RP 2] to speak to the resident to aid in calming him down. Writer spoke to son to provide information to the nights events. Resident is upset with the staff being in the facility. Resident keeps asking the staff when you leave are you gonna kill me. He is currently sitting at the nursing station in a chair. He is wearing his non skid footwear. Snacks have been offered. He reports no pain when asked. 7/11/23 6:23 a.m. Resident has had a substantial increase in behaviors. [PHY 1] was notified via phone. [PHY 1] Gave orders to increase [Quetiapine brand name] to 100 mg every 12 Hours. Resident was going to other resident's room telling them to get out of his house. Resident was trying to jump on beds and resident was screaming and everyone all night long. Resident was cussing at all the staff. Orders were carried out.Resident son [RP 2] was notified via phone of the changes in medications regimen. 7/12/23 2:22 a.m. Writer was informed by the CNA staff of the resident yelling get the [expletive] out of my house now. He is also going into other residents room demanding that they get the [expletive] out of his house now. Before his sister and brother come. Writer Resident is upset with the staff being in the facility. Resident keeps yelling and putting his fingers in the staff faces asking the staff when you leave. I will call the cops to arrest and shoot you guys. He is currently walking the halls of the facility. He is wearing his non skid footwear. Snacks have been offered. He reports no pain or any discomforts when asked. He just wants us out him house. 7/13/23 2:20 p.m. This order is outside of the recommended dose or frequency. [Brand name] Oral Tablet 5 MG (Aripiprazole) Give 1 tablet by mouth two times a day for Schizoaffective Disorder The frequency of 2 times per day exceeds the usual frequency of daily. During a concurrent interview and record review on 6/6/24 at 3:22 p.m., with MDS Nurse (MDSN) 1, Resident 75's Preadmission Screening and Resident Review (PASRR federal regulation that requires all individual being considered for admission to a Medicaid certified nursing facility be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition) dated 11/29/22, Resident 75's PASRR was reviewed. Resident 75's PASRR indicated, . no serious mental illness . result of level I screening negative. MDSN 1 acknowledged Resident 75's PASRR was conducted upon admission to the facility. During a telephone interview on 6/6/24 at 3:34 p.m., with Psychologist (PSYCH), when asked about Resident 75's diagnosis of schizoaffective disorder, PSYCH stated he did not have a copy of the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 (handbook that contains criteria for diagnosing mental disorders and is used by healthcare professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders) to review the criteria for diagnosis, and his best guess was that he carried the diagnosis forward and did not diagnose Resident 75 with bipolar or schizoaffective disorder. During a review of Resident 75's Minimum Data Set (MDS) (assessment and care screening of a patient) dated 12/1/22, 2/28/23, and 5/30/23, Resident 75's MDS indicated Resident 75 did not have a diagnosis for psychiatric or mood disorder including bipolar disorder (a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows) or schizophrenia, and Resident 75 did not have a history of hallucinations (when one thinks something they see, hear, smell, touch or taste is real, but it's not or delusions (inability to distinguish what is real and what seems to be real). During a concurrent telephone interview on 6/6/24 at 4:15 p.m., with PHY 1, PHY 1 stated Resident 75 had diagnoses including dementia, hearing loss, post CVA and hypertension. When asked why Resident 75's diagnosis of dementia was not updated on Resident 75's electronic medical record or Minimum Data Set (MDS a standardized comprehensive assessment and care planning tool), PHY 1 stated, If you look at my notes, I mentioned it a few times, its what the clinicians see, it should be there some place. PHY 1 stated he did not diagnose Resident 75 with schizoaffective disorder, and that it came from a psychiatrist. During a review of Resident 75's Nursing Progress Note (NPN) dated 5/24/23, Resident 75's NPN indicated, Writer contacted [PHY 1] by phone to notify him of the resident recent behaviors of getting into other residents' personal space, making threats and his non sleeping pattern. [PHY 1] gave new medication orders. MD gave orders for [Quetiapine brand name] 50 mg every 12 hours. MD was asked what diagnosis MD would like to give for this medication. MD stated schizoaffective disorder. PHY 1 stated he gave the schizoaffective disorder diagnosis and that with schizophrenia, there was no chemical test. PHY 1 stated he had use the diagnosis to justify putting Resident 75 on those medications. PHY 1 acknowledged he did not perform an evaluation of Resident 75 for bipolar disorder of schizoaffective disorder prior to Resident 75's diagnoses of bipolar disorder and schizoaffective disorder. When asked why Resident 75 concurrently on aripiprazole 5 mg twice daily from 7/13/23 to 10/24/23 and quetiapine 100 mg twice daily from 7/11/23 to 10/24/23, PHY 1 stated that was bad practice and he didn't think he would put Resident 75 on two antipsychotics (drugs that affects brain activities associated with mental processes and behavior) at the same time. PHY 1 stated he doubted he authenticated (verified) the orders and would increase the dose of one, and not both. PHY 1 stated side effects would include falls, and requested the orders be sent to him. PHY 1 stated Resident 75 was on hospice, and he didn't ask for hospice (program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) and didn't know why Resident 75 was on hospice. During a review of Resident 75's PO dated 7/11/23 and 7/13/23, Resident 75's PO for aripiprazole and quetiapine indicated PHY 1 electronically authenticated the telephone orders for Resident 75's concurrent use of quetiapine and aripiprazole. During a review of Resident 75's Physician Progress Notes (PPN), dated 2/19/23 and 3/19/23, the PPN dated 2/19/23 indicated, Dementia suspected and the PPN dated 3/19/23 indicated, Dementia. During a review of Resident 75's IDT Post Fall Review and Recommendation (PFRR) records, Resident 75's PFRR indicated Resident 75 suffered from falls on 7/31/23, 8/4/23, 8/16/23, 12/5/23, 2/25/24, 2/27/24, 3/5/24, 3/17/24 (2 falls), 3/19/24, 4/4/24. During a concurrent interview and record review on 6/7/24 at 10:09 a.m., with LVN 3, Resident 75's FS dated 6/7/24 and HMR dated 11/19/22 were reviewed. LVN 3 was unable to provide documentation of Resident 75's diagnosis of dementia among Resident 75's list of diagnoses. LVN 3 stated that for symptoms like forgetfulness, the psychiatrist would come in and evaluate. LVN 3 acknowledged Resident 75 was forgetful. LVN 3 acknowledged Resident 75's HMR indicated Resident 75 had underlying memory issues. During a concurrent telephone interview and record review on 6/7/24 at 3 p.m., with Registered Dietician (RD) 2, Resident 75's Weights and Vitals Summary Log (WVSL) dated 11/1/22 to 6/30/24 and Dietician Progress Notes (DPN) dated 12/29/22, 4/4/23, 6/9/23, 7/7/23, and 10/2/23 were reviewed. Resident 75's weight log indicated, 12/7/22 111 lbs [pounds], 2/13/23 115 lbs, 3/2/23 122 lbs, 4/4/23 125 lbs, 5/1/23 126 lbs, 6/5/23 132 lbs, 7/4/23 135 lbs, 8/1/23 140 lbs, 9/4/23 139 lbs, 10/2/23 143 lbs, 11/6/23 145 lbs, 12/1/23 144 lbs, 1/2/24 143 lbs, 2/13/24 113 lbs, 3/1/24 114 lbs, 4/1/24 106 lbs, 5/4/24 104 lbs 6/2/24 108 lbs. RD 2 acknowledged Resident 75's weight gain and stated Resident 75's ideal body weight was 106 to 130, body max index (BMI- indicates high body fat and screens for weight categories that may lead to health problems). A review of Resident 75's DPN dated 12/29/22 indicated, 4 lb weight gain since admission weight 12/7 111 lbs BMI: 4 normal consuming 75-100% of meals. Good appetite noted attributing to weight gain. A review of Resident 75's DPN dated 4/4/23 indicated, 125 lb, non-significant weight gain x [in] 1 month (3/2: 122 lbs) and significant 8.7% 10 lb weight gain x 3 months (1/4: 115 lb) BMI: 22.9 normal. Weight gain was desired. On house supplement TID [three times daily] attributing to weight gain. Social Services/Activities: On [Brand name] (aripiprazole) for bipolar which may cause weight gain . Recommend to reduce to 120 ml [milliliters] at dinner . A review of Resident 75's DPN dated 6/9/23 indicated, CBW 132 lbs 6/5, 4.8% 6 lb weight gain x 1 month (5/1 126 lbs, significant 8.2% 10 lbs weight gain x 3 months (3/2 122 lbs), significant 18.9% 21 lb weight gain x 6 month (12/7 111 lbs). BMI 24.1 normal. Weight gain desirable. Nursing: On [Quetiapine brand name]- can contribute to weight gain. A review of Resident 75's DPN dated 7/7/23 indicated, CBW [current body weight] 135 lbs 7/4, 3 lb wt [weight] gain x 1 month (6/5 132 lbs), significant 8% 10 lb wt gain x 3 months (4/4 125 lbs), significant 17.4% 20 lb wt gain x 6 months (1/4 115 lbs). BMI 24.7 normal Previously discontinued house supplement last month in IDT [Interdisciplinary Team- group of healthcare professionals from different fields working together to determine a patient's treatment plan] wt variance d/t [due to] adequate oral intake. Nursing: On [Quetiapine brand name]; potentially contributing to wt gain. Lipid panel and A1c ordered by MD for this month. A!c 6.6% . MD [PHY 1] advised to just watch his diet. A review of Resident 75's DPN dated 10/3/23 indicated, Value 143. Resident previously reviewed by IDT for significant wt change. Stable wt trend x 4 months. IDT to remain available and monitor on monthly weights. A review of Resident 75's DPN dated 11/6/23 indicated, CBW 145 lbs 11/6, wt gain x1 month (10/2 143 lbss), 5 lb wt gain x 3 months (8/1 140 lbs), significant 15.1% 19 lb wt gain x 6 months (5/1 126 lbs). BMI 26.5 overweight status . No additional supplements provided. RD 2 stated Resident 75 had a weight alert due to a significant weight gain during a six-month period. RD 2 stated he was part of the IDT meetings and they looked at different medications such as antipsychotics that could cause weight gain. RD 2 stated, he did not see any indication in Resident 75's medical record that would indicate fluid retention due to medications or diagnosis. RD 2 stated he was aware antipsychotic medication could cause weight gain. RD 2 stated for patient on medications, he may have spoken to the physician to determine if there was a different medication the resident can try, and the physician can order a more beneficial medication for the resident without the weight gain. During a concurrent interview and record review on 6/10/24 at 8:31 a.m., with Minimum Data Set Nurse (MDSN), MDSN stated she was not aware Resident 75 had a diagnosis of dementia. MDSN stated if Resident 75's physician diagnosed Resident 75 with dementia, it should be added that same day into Resident 75's profile because that would be the day the diagnosis became active. MDSN stated MDS staff is expected to review Resident 75's chart and input any new diagnosis. MDSN stated this was important because it could affect Resident 75's care; if all of staff is not aware Resident 75 has dementia, they might not know how to approach him or that he needs a different kind of approach. During a concurrent interview and record review on 6/10/24 at 8:41 a.m., with Administrator in Training (AIT), Resident 75's PO for aripiprazole and quetiapine were reviewed. AIT acknowledged being the assistant director of nursing at that time and confirming Resident 75's initial quetiapine order for 50 mg every 12 hours for schizoaffective disorder on 5/4/23. AIT stated Resident 75 was having behaviors and told a nursing staff to call PHY 1 and asked PHY 1 what diagnosis to put for Resident 75's order for quetiapine. AIT also acknowledged obtaining telephone orders for all of Resident 75's quetiapine and aripiprazole orders including aripiprazole 2 mg by mouth once daily for bipolar disorder manifested by slamming door shut, barricading door, and jumping on bed, on 3/4/23 with PHY 1, aripiprazole 5 mg by mouth once daily for schizoaffective disorder on 6/28/23, and aripiprazole 5 mg by mouth twice daily. AIT stated he was aware that quetiapine and aripiprazole were both antipsychotic medications and acknowledged Resident 75 was concurrently administered both quetiapine and aripiprazole. AIT acknowledged aripiprazole was not a twice daily dosing medication, and stated he presented all the information to PHY 1 and told PHY 1 all the medications Resident 75 was being administered and that is what PHY 1 gave the nursing staff. AIT stated, [Resident 75] was so unmanageable on our end]. AIT was unable to provide documentation indicating clinical rationale for dose increases of aripiprazole and quetiapine. AIT stated he did not remember Resident 75 having dementia and was aware some medications had black box warnings (highest safety-related warning that medications can have assigned by the Food and Drug Administration, a federal government agency). During a telephone interview on 6/10/24 at 9:16 a.m., with CRPH, CRPH stated aripiprazole is long acting and given once daily. CRPH stated if aripiprazole is given twice daily, it has more side effects. CRPH stated she has not seen it used twice daily. CRPH acknowledged the concurrent use of quetiapine and aripiprazole was inappropriate and stated the physician should be notified of therapy duplication because the medications can cause side effects. CRPH stated a majority of antipsychotics can cause weight gain, and weight gain was a major side effect of quetiapine. CRPH stated the expectation was to ask the physician to do a gradual dose reduction, lower dose to treat patient condition and lower risk of side effect. CRPH stated she was not aware Resident 75 was diagnosed with dysphagia and acknowledged antipsychotics can induce dysphagia. CRPH sated dysphagia was difficulty swallowing and could contribute to Resident 75's weight loss because Resident 75 would not be able to eat. CRPH stated it was important to consider alternative medications that would not cause dysphagia and to see if another resident condition could be inducing dysphagia. CRPH stated she was not aware Resident 75 was diagnosed with dementia and had not seen any dementia medication. CRPH stated there was a boxed warning that antipsychotics increase risk of cardiovascular mortality rate in the elderly and because of that, the physician should evaluate risk versus benefit. During a review of Lexicomp, the manufacturer for aripiprazole indicated, 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 . Avoid for behavioral problems associated with dementia or delirium unless alternative nonpharmacologic therapies have failed and patient may harm self or others. If used, consider deprescribing attempts to assess continued need and/or lowest effective dose . Aripiprazole may cause extrapyramidal symptoms (EPS), also known as drug-induced movement disorders . EPS presenting as dysphagia, esophageal motility disorder, or pulmonary aspiration [food, drink or other material enter lung] have also been reported with antipsychotics, which may not be recognized as EPS . All drugs may cause side effects. However, many people may not have side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away: . weight gain . During a review of Lexicomp, the manufacturer for quetiapine indicated, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine is not approved for the treatment of patients with dementia-related psychosis . Avoid for behavioral problems associated with dementia or delirium unless alternative nonpharmacologic therapies have failed and patient may harm self or others. If used, consider deprescribing attempts to assess continued need and/or lowest effective dose . Quetiapine may cause extrapyramidal symptoms (EPS), also known as drug-induced movement disorders . EPS presenting as dysphagia, esophageal motility disorder, or pulmonary aspiration [food, drink or other material enter lung] have also been reported with antipsychotics, which may not be recognized as EPS . All drugs may cause side effects. However, many people may not have side effects or only have minor side effects. Call your doctor or get medical help if any of these side effects or any other side effects bother you or do not go away: . weight gain . During a review of the Publication titled The American Psychiatric Association [APA] Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients With Dementia, dated 5/2016, the Publication indicated, Development of a Comprehensive Treatment Plan Statement 4. APA recommends that patients with dementia have a documented comprehensive treatment plan that inclu[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents right to be free from abuse (verbal and physical abuse) for one of three sampled residents (Resident 1) when Resident 2 hit Resident 1 on the right side of the face, in the same spot two times, threatened her and cursed at her. This failure resulted in Resident 1 experiencing fear, not wanting to leave her room to participate in activities or dine in the dining room from 2/7/23 to 2/9/23, an injury of pain and redness to the right side of her face with a pain rating (a way to measure pain so providers can help plan how best to manage the pain) of 8 out of 10 (zero means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) that required Oxycodone (an analgesic [acting to relieve pain] drug used to treat moderate to severe pain) which was avoidable. Findings: During a concurrent observation and interview on 2/9/23, at 1:55 p.m., with Resident 1, in Resident 1's room, Resident 1 was lying in bed. Resident 1's face was red, and her cheeks were patchy. Resident 1 had more red patchy area on the right side of her face than the left side. Resident 1 stated she had a history of her face turning red and developing a rash when she was stressed. Resident 1 stated Resident 2 used to be her roommate. Resident 1 stated on 2/6/23 Resident 2 was leaning over her while she was lying in bed and was screaming and cursing at her then hit her with a closed fist on the right side of her face two times. Resident 1 stated Resident 2 threatened her as she was leaving the room, stating Don't worry [Resident 1] I'm coming to get you and I will get you. Resident 1 stated she had a diagnosis of anxiety disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats leading to altered behavior and often to physical symptoms). Resident 1 stated she was hysterical (deriving from or affected by uncontrolled extreme emotion) and had a panic attack (a sudden feeling of acute and disabling anxiety) after being hit by Resident 2. Resident 1 stated she had severe pain to her face after being hit and was given medication. Resident 1 stated prior to the altercation with Resident 2 she used to eat meals in the dining room two times a week and attended activities in the dining room. Resident 1 stated she could not go to the dining room to eat or for activities after being hit by Resident 2 because she was too afraid and anxious she would see Resident 2 there. Resident 1 stated since being hit by Resident 2 on 2/6/23, she would become startled when the door to her room shuts too hard and when the lid to the clothing hamper in her room was closed. During a review of Resident 1's admission Record (AR), dated 2/9/23, the AR indicated Resident 1 had a diagnosis of Anxiety Disorder, Unspecified. During an interview on 2/14/23, at 10:00 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated he was working on 2/6/23 when Resident 1 and Resident 2 had an altercation. CNA 1 stated, he was in another resident's room when he heard shouting followed by a smack through the wall. CNA 1 stated he went to Resident 1 and Resident 2's room where he saw Resident 2 shouting and cursing at Resident 1. CNA 1 stated Resident 1 was upset and irritated. During an interview on 2/9/23, at 2:55 p.m., with Resident 2, Resident 2 stated she hit and slapped Resident 1 once or twice in the face on 2/6/23. During a review of Resident 2's admission Record (AR), dated 2/7/23, the AR indicated Resident 2 had the diagnoses of Unspecified Dementia (a mental disorder in which a person loses the ability to think, remember, learn make decisions, and solve problems) and Anxiety Disorder, Unspecified. During an interview on 2/7/23, at 10:51 a.m. with CNA 2, CNA 2 stated she was working on 2/2/23. CNA 2 stated around 7:00 a.m. she went into Resident 3's room because she heard gurgling noises. CNA 2 stated Resident 2 was lunged over Resident 3 with her hands on her neck. During a review of Resident 2's Progress Notes, dated 2/2/23, at [7:35 a.m.] the Progress Notes indicated, . [Resident 2] went to [Resident 3's] room because [Resident 3] was yelling. [Resident 2 stated that she put her hands on [Resident 3's] neck and told her to shut up . During a review of Resident 2's Progress Notes, dated 2/2/23, at [8:51 a.m.] the Progress Notes indicated, . [Resident 2] went to room [Resident 3's room] and was yelling at [Resident 3] and had put her hand on her neck to make her quiet . [Resident 2] was interviewed and [Resident 2] stated that [Resident 3] was yelling and she had to take care of it [Resident 2] stated that she put her hands around [Resident 3's] neck . During a review of Resident 2's Care Plan, dated 2/2/23, the Care Plan indicated, . [Resident 2] was alleged for putting her hands around a [Resident 3's] neck . Goal [Resident 2] will have no other episodes of this behavior . Interventions . Monitor [Resident 2] every 15 [minutes] for whereabouts . During an interview on 2/9/23, at 2:57 p.m., with the Activities Assistant (AA), the AA stated he kept track of what residents in the facility were participating in having meals in the dining room. The AA stated prior to the altercation on 2/6/23, Resident 1 normally ate in the dining room. The AA stated Resident 1 had not been to the dining room since 2/7/23 and had been not leaving her room since the altercation. During an interview on 2/9/23, at 3:16 p.m., with the Activities Director (AD) the AD stated she was familiar with Resident 1. The AD stated Resident 1, prior to the altercation on 2/6/23, participated in getting her nails done, movie socials, coffee socials and liked to be in the front lobby area of the facility. The AD stated Resident 1 liked to have lunch in the dining area. The AD stated Resident 1 was leaving her room prior to the altercation with Resident 2. The AD stated she had not seen Resident 1 leave her room since the altercation with Resident 2 on 2/6/23. During a concurrent observation and interview on 2/9/23, at 3:57 p.m., with the Resident 1 and the AD, in Resident 1's room, Resident 1 was lying in bed. Resident 1 stated she wanted to go to the dining room for meals but was fearful and did not want to see Resident 2. The AD stated Resident 1 was fearful and did not want to see Resident 2. During a concurrent observation and interview on 2/10/23, at 10:15 a.m., with Resident 2, in Resident 2's room, Resident 2 was sitting in her bed. Resident 2 stated she did not do what was right with Resident 1. Resident 2 stated what was right would be knocking her out. During an observation on 2/10/23, at 10:19 a.m., in the dining room, there were 12 residents having coffee. Resident 1 was not in attendance in the dining room. During an interview on 2/10/23, at 10:48 a.m., with Social Services Director (SSD) 1, SSD 1 stated Resident 1 was scared to be out of her room in the facility to do activities if Resident 2 was there. SSD 1 stated Resident 1 could hear Resident 2's voice while in her room and became scared Resident 2 would come in her room. SSD 1 stated Resident 1 ate meals in the dining room two to three times a week for lunch or dinner prior to the altercation with Resident 2. SSD 1 stated Resident 1 participated in activities two to three times a week prior to the altercation with Resident 2. SSD 1 stated Resident 1 had not been leaving her room since the altercation on 2/6/23 with Resident 2. During an interview on 3/15/23, at 10:34 a.m., with the Certified Dietary Manager (CDM), the CDM stated Resident 1 was not dining in the dining room for any meals. The CDM stated there was no way to look at previous dates to find where Resident 1 was eating her meals prior to the altercation on 2/6/23. The CDM stated she was only able to look at meal location for Resident 1 on the current date. During an interview on 3/15/23, at 11:07 a.m., with the Restorative Nursing Assistant (RNA), the RNA stated, she was familiar with Resident 1. The RNA stated Resident 1 was coming to the dining room twice a week prior to altercation with Resident 2. The RNA stated after the altercation with Resident 2, Resident 1 did not come to the dining room to eat. The RNA stated after the altercation, there were several days that week she didn't come out of her room at all. The RNA stated Resident 1 was afraid and teared up when talking about the altercation. During a review of Resident 1's Diet Order, dated 3/20/23, the Diet Order indicated . [Resident 1] . Breakfast . Dining Location: Eats in Room . Lunch . Dining Location: Eats in Room . Dinner . Dining Location: Eats in Room . During an interview on 3/15/23, at 2:59 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he was working on 2/6/23 when Resident 1 and Resident 2 had an altercation. LVN 1 stated the altercation between Resident 1 and Resident 2 happened around 10:45 p.m. LVN 1 stated he heard screaming coming from their shared room. LVN 1 stated that Resident 2 was cursing at Resident 1. LVN 1 stated Resident 2 threatened to physically harm Resident 1. LVN 1 stated Resident 1 was scared and crying. LVN 1 stated Resident 1 was shaking, stuttering and unable to speak properly. LVN 1 stated Resident 1 had redness to the right side of her face. LVN 1 stated Resident 1 required medication for pain after the altercation. LVN 1 stated Resident 1 had a pain level of 8 out of 10 and he administered her Oxycodone. During a review of Resident 1's Progress Notes, dated 2/6/23, the Progress Notes indicated, . At [11:45 p.m.] there was a lot of shouting from the resident's room . [Resident 2] was cussing profusely and making threats to physically hurt the resident [Resident 1] . [Resident 1] seemed extremely scared . Upon skin assessment the [Resident 1] had redness to the right side of the face . [Resident 1] also stated that [Resident 2] slapped [Resident 1] multiple times in the face . During a review of Resident 1's Progress Notes, dated 2/7/23, at [2:13 p.m.] the Progress Notes indicated, . [Resident 1] reports right side of her face hurts . During a review of Resident 1's Progress Notes, dated 2/7/23, at [11:05 p.m.], the Progress Notes indicated, redness to right side face decreased almost to normal skin tone . During a review of Resident 1's Medication Admin Audit Report (MAAR), dated 3/15/23, the MAAR indicated, Resident 1 was administered Oxycodone HCl tablet 10 MG (milligram) on 2/7/23 at 12:39 a.m. During an interview on 3/15/23, at 1:05 p.m., with Social Services Designee (SSD) 2, SSD 2 stated, he met with Resident 1 on 2/8/23 Resident 1's room. SSD 2 stated Resident 1 had redness to the right side of her face. SSD 2 stated Resident 1 wanted the door to her room closed but remained scared with the door closed. SSD 2 stated he could tell Resident 2 was scared based on his interactions with her while working at the facility for two to three years. SSD 2 stated Resident 1 was fidgety. SSD 2 stated prior to the altercation with Resident 2, Resident 1 would eat in the dining area two times a week and would be out of her room four days a week. SSD 2 stated after the altercation with Resident 2, he did not see Resident 1 come out of her room for a week. During a review of Resident 1's Progress Notes, dated 2/8/23, the Progress Notes indicated, . [Resident 1] stated she does feel scared . During an interview on 3/16/23, at 12:42 p.m., with the AA, the AA stated he documented daily activities for residents at the facility. The AA stated Resident 1 attended a group activity outside of her room on 1/13/23, 1/17/23, 1/19/23, 1/20/23, 1/25/23, 1/26/23, 1/27/23, 1/28/23, 1/31/23 2/1/23, 2/2/23. The AA stated there was no record of Resident 1 participating in any activities on 2/7/23. The AA stated Resident 1 did not participate in out of the room activity on 2/8/23 and 2/9/23. The AA stated he met with Resident 1 on 2/9/23 in her room. The AA stated Resident 1 was afraid of Resident 2 and did not want to come out of the room. The AA stated Resident 1 appeared nervous, apprehensive, and depressed. During a review Resident 1's Follow Up Question Report (FUQR), dated 3/16/23, the FUQR indicated Resident 1 had participated in activities outside of her room as a group on 1/13/23, 1/17/23, 1/19/23, 1/20/23, 1/25/23, 1/26/23, 1/27/23, 1/28/23, 1/31/23, 2/1/23 and 2/2/23. The FUQR indicated no record of activity on 2/7/23. The FUQR indicated Resident 1 did not participate in a group activity outside of the room on 2/8/23 or 2/9/23. The FUQR indicated Resident 1 had a 1:1 (meeting in person between two people) with the AA on 2/9/23. During an interview on 3/15/23, at 2:06 p.m., with SSD 1, SSD 1 stated if a resident was abused and no longer wanted to leave their room out fear, the resident would be experiencing psychosocial distress (an unpleasant emotional experience). SSD 1 stated Resident 1 experienced psychosocial distress for four days following the altercation with Resident 2. During a review of Resident 1's Progress Notes, dated 2/8/23, the Progress Notes indicated, . [SSD 1] spoke with [Resident 1] about being scared. [Resident 1] stated she does want [Resident 2] to know where she is at. [SSD 1] reassured [Resident 1] that [Resident 2] does not know what room she is in . [SSD 1] asked [Resident 1] that arrangement were made in dining room if [Resident 1] wanted to attend. [Resident 1] declined at this time. [Resident 1] stated she can hear [Resident 2] close to her room. [SSD 1] assured [Resident 1] that her room is next to the dining room and [Resident 2] voice is echoing and that's why she can hear [duplicate word] her and sounds close by . During an interview on 3/17/23, at 1:55 p.m., with SSD 1. SSD 1 stated there had been a previous altercation between Resident 2 and another resident at the facility. SSD 1 stated Resident 2's prior altercation with Resident 3 was serious. SSD 1 stated the interventions put in place by the facility for Resident 2 were not effective. SSD 1 stated if Resident 2 had an intervention for one-on-one sitter monitoring (aimed to keep residents safe through direct observation by staff at all times) the altercation with Resident 1 could have been avoided. SSD 1 stated the residents at the facility had the right to be free from abuse. SSD 1 stated being hit was physical abuse. SSD 1 stated she made a progress note on 2/8/23, at 4:00 p.m. that had an error documented. SSD 1 stated the progress note should have said Resident 1 did not want Resident 2 to know where she was located at the facility. During an interview on 3/17/23, at 2:21 p.m. with the Director of Nursing (DON), the DON stated, Resident 2 had a previous altercation with another resident prior to the altercation with Resident 1. The DON stated Resident 2's previous altercation where she wrapped her hands around Resident 3's neck was serious. The DON stated the interventions put in place by the facility for Resident 2's previous altercation did not work and were not enough to keep her from another altercation with Resident 1. The DON stated if Resident 2 had an intervention in place for a one-on-one sitter monitoring the altercation with Resident 1 would not have happened. The DON stated the residents at the facility had the right to be free from abuse. The DON stated being hit, being threatened, and cursed at was abuse. During a review of the facility's policy and Procedure (P&P) titled, Preventing, Investigating, and Reporting Alleged Sexual and Abuse Violation, dated 2017, the P&P indicated, . Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting physical harm, pain or mental anguish . Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents . Examples of verbal abuse include . threats of harm . saying things to frighten a resident . Physical Abuse includes hitting, slapping . Appropriate steps are taken to prevent recurrence of the incident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet the pain management needs of residents consistent with professional standards of practice for one of five sampled residents (Resident 1) when Resident 1's pain level of 10 out of 10 (a pain scale used to evaluate pain; 0 - no pain, 1 to 3 - mild pain, 4 to 7 - moderate, 8 to 10 - severe pain) was not managed effectively due to unavailability of Resident 1's Carbamazepine (medication used to treat certain types of nerve pain) and Licensed Nurses (LN) did not assess the pain, document, and notify the physician (MD – Medical Doctor) of Resident 1's severe pain in order to provide possible alternatives to address the pain. This failure resulted in Resident 1 experiencing avoidable severe uncontrolled pain (10 out of 10) and suffering for prolonged periods of time from 1/24/23 through 1/25/23 which led to her inability to sleep at night, crying, and unable to receive needed care due to severe pain to the areas of her body affected by pain. Findings: During a concurrent observation and interview on 2/6/23, at 10:30 a.m., in Resident 1's room, Resident 1 was in bed, awake. Resident 1 stated she did not receive her Carbamazepine for two days (1/24/23 and 1/25/23). Resident 1 stated she took her pain medications three times daily. Resident 1 stated, I can miss one to two doses, but I can't miss more than that and experienced 10 out of 10 on pain scale . Resident 1 stated, I live in fear that the facility will run out of my medication . I was crying in pain, but movement of my face while crying made my whole body feel like it was on fire. Resident 1 stated the facility missed four doses of pain medications because the facility ran out of supply of Carbamazepine. Resident 1 stated she informed staff of her pain level and the Licensed Nurses offered Ibuprofen (pain medication used to relieve mild pain). During a review of Resident 1's Face Sheet (FS) the FS indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of . Multiple Sclerosis (a condition wherein the body's immune system eats away at the protective covering of nerves) . Neuralgia (facial nerve pain caused by injury or infection or by damage of the nerve) . During a telephone interview on 2/6/23, at 12:35 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was assigned to Resident 1 on 1/24/23 (morning shift). CNA 1 stated she was cleaning Resident 1's face with a washcloth and Resident 1 told her she was in pain. CNA 1 stated she tried to brush Resident 1's teeth and Resident 1 told CNA 1 to stop because it hurt around her face and mouth. CNA 1 stated Resident 1 withdrew away while I was cleaning her face. CNA 1 stated, I was unable to apply lotion to her face or brush her teeth because Resident 1 did not want me to do it due to pain. CNA 1 stated Resident 1 told CNA 1 they (the facility) had run out of her pain medications. CNA 1 stated she went to the assigned LN to notify her of Resident 1's pain. CNA 1 stated LN told her Resident 1 was in pain because she was out of her medication. CNA 1 stated she worked the next day (1/25/23) and Resident 1 told her the pain was worse than the day before. During a concurrent interview and record review, on 2/6/23, at 1:15 p.m., with LN 1, Resident 1's Medication Administration Record (MAR) dated 1/2023 was reviewed. The MAR indicated, . Carbamazepine tablet 200 milligrams [mg, unit of measure] by mouth three times daily, related to muscle spasm pain . The administration date of 1/24/23 at 4:00 p.m. indicated a number 11 in the MAR box for Carbamazepine 200 mg. LN 1 stated the number 11 meant the medication was unavailable. LN1 stated the Carbamazepine for Resident 1 were also not given on 1/24/23 at 12:00a.m., 1/25/23 at 8:00 a.m., and 1/25/23 at 4:00 p.m. LN 1 stated Resident 1 missed 4 doses of her Carbamazepine. LN 1 stated she did not notify the MD and did not document the missed dosed of the pain medication. During a telephone interview on 2/6/23 at 2:00 p.m., with CNA 3, CNA 3 stated she was familiar with Resident 1 and cared for her in the past. CNA 3 stated Resident 1 made her needs known verbally. CNA 3 stated that it was the CNAs responsibility to alert the charge nurse when a resident was complaining of pain. CNA 3 stated, she was not assigned to resident 1 on 1/24/23 and 1/25/23. During a review of Resident 1's Care Plan (CP), dated 2/6/23, the CP indicated, . Administer pain medication as ordered . Evaluate and Establish level of pain on numeric scale/evaluation tool . Utilize pain monitoring tool to evaluate effectiveness of interventions . Patient will achieve acceptable pain level goal . During an interview on 2/7/23, at 9:15 a.m., with LN 2, LN 2 stated she did not give Resident 1 her pain medication (Carbamazepine) on 1/25/23 on the a.m. shift. LN 2 stated the medication was not available in the medication cart. LN 2 stated CNA 1 had come to her in the early afternoon of 1/25/23 to let her know Resident 1 was experiencing 10 out of 10 pain to her face, was feeling hot and that her whole body hurt. LN 2 stated she went to see Resident 1 in her room and Resident 1 told her it felt like her body was on fire and rated her pain level at a 10 out of 10 on the pain scale. LN 2 stated she offered Resident 1 ibuprofen. LN 2 stated she asked Resident 1 if she wanted to go to the hospital, and Resident 1 refused. LN 2 stated she did not document that encounter with Resident 1 being in pain in progress notes. LN 2 stated she should have called Resident 1's Medical Doctor when Resident 1 complained of feeling hot, her whole body hurting and 10 out of 10 pain level. LN 2 stated Resident 1's complaints were unusual. LN 2 stated she should have notified the Charge Nurse or the Director of Nursing (DON) to alert them about Resident 1's condition. During a concurrent interview on 2/7/23, at 10:00 a.m., with the DON, the DON stated Resident 1's complaint of feeling hot, full body aches, and pain level 10 out of 10 should have been addressed immediately. DON stated LN 2 should have completed a pain assessment of Resident 1, notified the MD and documented her findings. DON stated there were no documentation regarding Resident 1's pain in the progress notes. DON stated LN 2 did not follow the standard of practice. During an interview on 2/7/23, at 10:50 a.m., with LN 2, LN 2 stated, I was not aware I was supposed to call the MD when a medication is not available for a resident. LN 2 stated, Residents should not run out of any medications. LN 2 stated, Resident 1 experienced 10 out of 10 pain due to her pain medications not being available. LN 2 stated that it was important to have a complete and accurate pain assessment to include the level of pain, quality, region of the body, severity, and time to look back on and evaluate the underlying cause of the pain. LN 2 stated, If it's not documented, then it's not done. During an interview on 2/7/23, with DON, at 11:00 a.m., DON stated Resident 1 experienced pain due to the number of missed doses of pain medications. DON stated residents should not run out of needed medications. DON stated it unacceptable for resident to be in pain when there was an ordered pain medication. During a concurrent observation and interview on 2/7/23, at 12:15 p.m., in Resident 1's room, Resident was in bed, resting. Resident 1 stated, I asked CNA 1 not to touch around my face or brush my teeth due to pain of 10 out of 10 to my face. Resident 1 stated she had a pain level of 10 out of 10 and did not sleep during the night on 1/24/23. Resident 1 stated she experienced episodes of 10 out of 10 pain on 1/25/23 throughout the day. Resident 1 stated she did not receive her pain medications on 1/24/23 and 1/25/23. During a telephone interview on 2/7/23, at 12:52 p.m., with the facility's consultant Pharmacist, Pharmacist stated refill orders for medications were faxed by the facility which started the process to meet the facility's medications needs. Pharmacist stated that he received the fax from the facility for the Carbamazepine for Resident 1 on 1/23/23. Pharmacist stated the facility needed to reorder medications 3 to 5 days in advance (the facility's practice according to the policy) so they (Pharmacy) had enough time to process the order and get the medications delivered. During a review of the contracted pharmacy documentation titled, Pharmacy Refill Request, dated 1/2023, the document indicated, Carbamazepine for Resident 1 was reordered by the facility on 1/23/23 at 1:52 p.m. and the medication was delivered on 1/25/23 between 2:30 p.m. and 11 p.m. During an interview on 2/7/23, at 2:40 p.m., with LN 3, LN 3 stated, Resident 1 was alert and oriented and able to verbalize her needs and pain level. LN 3 stated residents' medications needed to be reordered 3-5 days on before they run out of their medication. LN 3 stated the Carbamazepine should have been reordered on 1/21/23. LN 3 stated, Resident 1's medication should have not been allowed to run out because Resident 1 can suffer moderate to severe pain. LN 3 stated, If a resident misses a dose of any medication, it is my responsibility to call the Pharmacy, Director of Nursing, and Medical Doctor and let them know Resident 1's medication was not available. LN 3 stated, she didn't think about calling the MD. LN 3 stated, the standard of practice was to call the MD and provide information so MD may order an alternative medication to keep resident from being in severe pain. During a telephone interview on 2/8/23, at 9:30 a.m., with the MD, the MD stated he did not recall receiving notification from the LNs regarding Resident 1's medication not being available. MD stated when Resident 1 missed 3-4 doses of the medication resident (Resident 1) would have increased pain. MD stated the resident could experience pain if they don't receive the medication as ordered. MD stated he was not notified by Licensed Nurses, when Resident 1 was having 10 out of 10 pain level. MD stated licensed Nurses should have notified him. MD stated he expected the Licensed Nurses to call him when Resident 1 was in pain. MD stated it was very important for Licensed Nurses to call if Resident 1 was out of Carbamazepine so he could provide a substitute medication. During an interview on 2/8/23, at 9:50 a.m., with LN 5, LN 5 stated Resident 1 was out of her medication for pain and she filled out the pharmacy form to reorder the medication. LN 5 stated she did not call the Assistant Director of Nursing (ADON) or DON. LN stated she did not notify the MD for the missed doses of Carbamazepine medication. LN 5 stated she didn't feel the need to call the MD because Resident 1 had gone for days (1/24/23 to 1/25/23) without the medication. LN 5 stated she told Resident 1 her medication was not available. LN 5 stated, Resident 1 gets upset when her medications run out and feels that it will be days before the medications come in. LN 5 stated, she did not document that conversation with Resident 1. During an interview on 2/8/23, at 11:15 a.m. with LN 6, LN 6 stated, she worked the p.m. shift on 1/25/23. LN 6 stated, the Carbamazepine tablet 200 mg (milligrams – unit of measure) was not available for the 4:00 p.m. administration time for Resident 1. LN 6 stated she completed her p.m. (afternoon/evening) medication pass and called the pharmacy to inquire about the medication. LN 6 stated she did not call the MD to let him know of the missed dose. LN 6 stated, she should have called the MD and alerted the DON or ADON of the unavailability of the medication. During a concurrent observation, interview and record review on 2/9/23, at 4:00p.m., in the DON's office, the ADON brought in staff In-service documents. DON stated, in-services were immediately provided to the staff. A review of the facility's Lesson Plan on Pain In-service, indicated, . Pain In-Service . Identify appropriate assessments of pain and different scales of pain and how to apply them to patient situations . A review of the Lesson Plan on Pharmacy Procedures and Communications, indicated, . Know what a satellite pharmacy and how to request STAT medications . Notification to MD, DON, and ADON of missing medications . Charting and Progress notes . Pharmacy medications and Delivery Procedures . During a review of the facility document titled, Job Description . Director of Nursing, dated 11/2016, the document indicated, . Manage and directs all aspects of the Nursing Services Department . ensure nursing personnel perform their work assignments in accordance with acceptable nursing standards . Review nursing personnel medical record documentation to ensure it is appropriately and accurately descriptive of the nursing care provided . During a review of the facility document titled, Job Description . Licensed Vocational Nurse, dated 11/2016, the document indicated, . The LVN [Licensed Nurse] is also responsible for the delivery of medications to residents in accordance with physician's orders . Organize central storage and delivery of medications for each shift. Assist with pharmacy delivery of medications . Order medications as needed . Ensure proper documentation of medication changes, new orders and refill order . During a review of the facility's policy and procedure (P&P) titled, Pain Management Guideline, undated, the P&P indicated, . To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort . Recognize that patients who have chronic pain will benefit most from an effective, scheduled pain medication regimen . Intervening to treat pain before pain becomes severe . Understanding the importance of effective pain management for quality of life . Documentation may appear on the following . Pain Evaluation . Pain Monitoring Tool . Nursing Progress Notes . Care Plan . During a review of pharmacy policy titled Medication Ordering and Receiving from Pharmacy, dated 1/2022, the policy indicated, . Ordering medications from the dispensing Pharmacy . Medication orders are written on a medication order form provided by the pharmacy The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy . Reorder medication three to four days in advance of need, as directed by the pharmacy order and delivery schedule, to assure adequate supply is on hand . During a review of professional reference titled Pain Assessment and Management – Understanding the Requirements , dated 10/21/21, retrieved from https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/provision-of-care-treatment-and-services-pc/000002161/ indicated, . A 'screening' is a process for evaluating the possible presence of a problem. An 'assessment' gathers more detailed information through collection of data, observation, and physical examination. Assessments are completed individuals deemed qualified through education, training, licensure, etc., to conduct such evaluations. Pain assessment tools are generally evidence-based and often include, at a minimum, an evaluation of pain intensity, location, quality, and associated symptoms. An accurate pain screening and assessment is the foundation on which an individualized, effective pain management plan is developed. For example, a pain 'screening' may be used to determine if the patient has pain or not. If the patient answers yes, a comprehensive pain assessment would be indicated . Organizations are responsible for ensuring that appropriate screening and assessment tools are readily available and used appropriately . During a review of the professional reference titled, Lippincott Manual of Nursing Practice 11th edition (dated) 2020, page 15 indicated, . Standards of Practice . General Principles . 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable . b. These standards provide patients with a means of measuring the quality of care they receive . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: . follow physician orders . document appropriate information in the medical record . and follow physician's orders . Failure to implement a physician's . order properly . During a review of the professional reference titled Pain Management in the Geriatric Population, undated, retrieved from https://musculoskeletalkey.com/pain-management-in-the-geriatric-population/ .uncontrolled . Persistent pain may lead to functional loss, including impaired mobility and activities of daily life (ADL's) and generally reduced the Quality of life .pain can result in a significant physical and social consequences . Elderly with untreated pain may have exacerbation of cognitive impairment, mental health issues such as depression, and anxiety, and sleep disturbance .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents for two of three samples residents (Resident 1 and Resident 2) when: 1.Resident 1 did not receive her Carbamazepine (medication used to treat severe pain for facial neuralgia) for two days (four scheduled doses) due to the medication not being re-ordered timely (Within 3-5 days of medications running out). This failure resulted in Resident 1 to experience avoidable severe pain, measured as 10 of 10, which caused her suffering, bouts of crying and inability for staff to provide needed care to parts of her face. 2.Resident 2 did not receive his Lidocaine patch (an adhesive material used to relieve pain) for 12 days due to Licensed Nurses not being aware of the available stock supply of Lidocaine patches in the medication room. This failure placed Resident 2 at a potential risk to experience severe pain to his back. Findings: During a concurrent observation and interview on 2/6/23, at 10:30 a.m., in Resident 1's room, Resident 1 was in bed, awake. Resident 1 stated she did not receive her Carbamazepine for two days (1/24/23 and 1/25/23). Resident 1 stated she took her pain medications three times daily. Resident 1 stated, I can miss one to two doses, but I can't miss more than that and experienced 10 out of 10 on pain scale . Resident 1 stated, I live in fear that the facility will run out of my medication . I was crying in pain, but movement of my face while crying made my whole body feel like it was on fire. Resident 1 stated the facility missed four doses of pain medications because the facility ran out of supply of Carbamazepine. Resident 1 stated she informed staff of her pain level and the Licensed Nurses offered Ibuprofen (pain medication used to relieve mild pain). During a review of Resident 1's Face Sheet (FS) the FS indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of . Multiple Sclerosis (a condition wherein the body's immune system eats away at the protective covering of nerves) . Neuralgia (facial nerve pain caused by injury or infection or by damage of the nerve) . During a telephone interview on 2/6/23, at 12:35 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated she was assigned to Resident 1 on 1/24/23 (morning shift). CNA 1 stated she was cleaning Resident 1's face with a washcloth and Resident 1 told her she was in pain. CNA 1 stated she tried to brush Resident 1's teeth and Resident 1 told CNA 1 to stop because it hurt around her face and mouth. CNA 1 stated Resident 1 withdrew away while I was cleaning her face. CNA 1 stated, I was unable to apply lotion to her face or brush her teeth because Resident 1 did not want me to do it due to pain. CNA 1 stated Resident 1 told CNA 1 they (the facility) had run out of her pain medications. CNA 1 stated she went to the assigned Licensed Nurse (LN) to notify her of Resident 1's pain. CNA 1 stated LN told her Resident 1 was in pain because she was out of her medication. CNA 1 stated she worked the next day (1/25/23) and Resident 1 told her the pain was worse than the day before. During a concurrent interview and record review, on 2/6/23, at 1:15 p.m., with LN 1, Resident 1's Medication Administration Record (MAR) dated January 2023 was reviewed. The MAR indicated, . Carbamazepine tablet 200 milligrams [mg, unit of measure] by mouth three times daily, related to muscle spasm pain . The administration date of 1/24/23 at 4:00 p.m. indicated a number 11 in the MAR box for Carbamazepine 200 mg. LN 1 stated the number 11 meant the medication was unavailable. LN 1 stated the Carbamazepine for Resident 1 were also not given on 1/24/23 at 12:00a.m., 1/25/23 at 8:00 a.m., and 1/25/23 at 4:00 p.m. LN 1 stated Resident 1 missed 4 doses of her Carbamazepine. LN 1 stated she did not notify the MD and did not document the missed dosed of the pain medication. During a review of Resident 1's Care Plan (CP), dated 2/6/23, the CP indicated, . Administer pain medication as ordered . Evaluate and Establish level of pain on numeric scale/evaluation tool . Utilize pain monitoring tool to evaluate effectiveness of interventions . Patient will achieve acceptable pain level goal . During an interview on 2/7/23, at 9:15 a.m., with LN 2, LN 2 stated she did not give Resident 1 her pain medication (Carbamazepine) on 1/25/23 on the a.m. shift. LN 2 stated the medication was not available in the medication cart. LN 2 stated CNA 1 had come to her in the early afternoon of 1/25/23 to let her know Resident 1 was experiencing 10 out of 10 pain to her face, was feeling hot and that her whole body hurt. LN 2 stated she went to see Resident 1 in her room and Resident 1 told her it felt like her body was on fire and rated her pain level at a 10 out of 10 on the pain scale. LN 2 stated she offered Resident 1 ibuprofen. LN 2 stated she asked Resident 1 if she wanted to go to the hospital, and Resident 1 refused. LN 2 stated she did not document that encounter with Resident 1 being in pain in progress notes. LN 2 stated she should have called Resident 1's Medical Doctor when Resident 1 complained of feeling hot, her whole body hurting and 10 out of 10 pain level. LN 2 stated Resident 1's complaints were unusual. LN 2 stated she should have notified the Charge Nurse or the Director of Nursing (DON) to alert them about Resident 1's condition. During a concurrent interview on 2/7/23, at 10:00 a.m., with Director of Nursing (DON), the DON stated Resident 1's complaint of feeling hot, full body aches, and pain level 10 out of 10 should have been addressed immediately. The DON stated LN 2 should have completed a pain assessment of Resident 1, notified the MD and documented her findings. The DON stated there were no documentation in Resident 1's progress notes. The DON stated LN 2 did not follow the standard of practice. During an interview on 2/7/23, at 10:50 a.m., with LN 2, LN 2 stated, I was not aware I was supposed to call the MD when a medication is not available for a resident. LN 2 stated, residents should not run out of any medications. LN 2 stated, Resident 1 experienced 10 out of 10 pain scale due to her pain medications were not available. LN 2 stated that it was important to have a complete accurate pain assessment to include the level of pain, quality, region, severity, and time to have a trail to look back on and evaluate the underlying cause of the pain. LN 2 stated If it's not documented, then it's not done. During an interview on 2/7/23, at 11:00 a.m., with the DON, the DON stated the Licensed Nurses were to call the pharmacy right away to follow up on a refill order. The DON stated all resident medications documented on the MAR as unavailable should have been followed up with a call to the Medical Doctor (MD). The DON stated, she was unable to verify if the LNs' called the pharmacy because there was no documentation. The DON stated, Resident 1 should not have missed her medication because it was ordered specifically for her diagnosis Neuralgia (pain caused by damaged nerves). The DON stated, the LN's did not alert her of the unavailable medication for Resident 1. During a concurrent observation and interview on 2/7/23, at 12:15 p.m., in Resident 1's room, Resident was in bed, resting. Resident 1 stated, I asked CNA 1 not to touch around my face or brush my teeth due to pain of 10 out of 10 to my face. Resident 1 stated she had a pain level of 10 out of 10 and did not sleep during the night on 1/24/2023. Resident 1 stated she experienced episodes of 10 out of 10 pain on 1/25/23 throughout the day. Resident 1 stated she did not receive her pain medications on 1/24/23 and 1/25/23. During a telephone interview on 2/7/23, at 12:52 p.m., with the facility's consultant Pharmacist, Pharmacist stated refill orders for medications were faxed by the facility which started the process to meet the facility's medications needs. Pharmacist stated that he received the fax from the facility for the Carbamazepine for Resident 1 on 1/23/23. Pharmacist stated the facility needed to reorder medications 3 to 5 days in advance so they (Pharmacy) had enough time to process the order and get the medications delivered. The medication for Resident 1 should have been reordered on 1/21/23. During a review of the contracted pharmacy documentation titled, Pharmacy Refill Request, dated 1/2023, the document indicated, Carbamazepine for Resident 1 was reordered by the facility on 1/23/23 at 1:52 p.m. and the medication was delivered on 1/25/23 between 2:30 p.m. and 11 p.m. During an interview on 2/7/23, at 2:40 p.m., with LN 3, LN 3 stated, Resident 1 was alert and oriented and able to verbalize her needs and pain level. LN 3 stated residents' medications needed to be reordered 3-5 days on before they run out of their medication. LN 3 stated the Carbamazepine should have been reordered on 1/21/23. LN 3 stated, Resident 1's medication should have not been allowed to run out because Resident 1 can suffer moderate to severe pain. LN 3 stated, If a resident misses a dose of any medication, it is my responsibility to call the Pharmacy, Director of Nursing, and Medical Doctor and let them know Resident 1's medication was not available. LN 3 stated, she didn't think about calling the MD. LN 3 stated, the standard of practice was to call the MD and provide information so MD may order an alternative medication to keep resident from being in severe pain. During an interview on 2/7/23, at 4:00 p.m., with the Assistant Director of Nursing (ADON), the ADON stated, When a resident runs out of their medications, staff must call the pharmacy to follow up on the medication . residents should not run out of their medications. The ADON stated it was the LN's responsibility to call the MD when resident's medications were unavailable. The ADON stated, it was important to have a complete and accurate pain assessment to include the level of pain, quality, region, severity, and time to have a trail to look back on and evaluate the underlying cause of the pain. During a telephone interview on 2/8/23, at 9:30 a.m., with the MD, the MD stated he did not recall receiving notification from the LNs regarding Resident 1's medication not being available. The MD stated when Resident 1 missed 3-4 doses of the medication resident (Resident 1) would have increased pain. The MD stated the resident could experience pain if they don't receive the medication as ordered. The MD stated he was not notified by Licensed Nurses, when Resident 1 was having 10 out of 10 pain level. The MD stated licensed Nurses should have notified him. The MD stated he expected the Licensed Nurses to call him when Resident 1 was in pain. The MD stated it was very important for Licensed Nurses to call if Resident 1 was out of Carbamazepine so he could provide a substitute medication. During an interview on 2/8/23, at 9:50 a.m., with LN 5, LN 5 stated Resident 1 was out of her medication for pain and she filled out the pharmacy form to reorder the medication. LN 5 stated she did not call the Assistant Director of Nursing (ADON) or DON. LN stated she did not notify the MD for the missed doses of Carbamazepine medication. LN 5 stated she didn't feel the need to call the MD because Resident 1 had gone for days without the medication. LN 5 stated she told Resident 1 her medication was not available. LN 5 stated, Resident 1 gets upset when her medications run out and feels that it will be days before the medications come in. LN 5 stated, she did not document that conversation with Resident 1. During an interview on 2/8/23, at 11:15 a.m. with LN 6, LN 6 stated, she worked the p.m. shift on 1/25/23. LN 6 stated, the Carbamazepine tablet 200 MG was not available for the 4:00 p.m. administration time for Resident 1. LN 6 stated she completed her p.m. (afternoon/evening) medication pass and called the pharmacy to inquire about the medication. LN 6 stated she did not call the MD to let him know of the missed dose. LN 6 stated, she should have called the MD and alerted the DON or ADON of the unavailability of the medication. 2. During an interview on 2/6/23, at 11:30 a.m., with Resident 2, Resident 2 stated, he did not receive his Lidocaine Patch (a medication used to relieve pain) for several periods of time and experienced pain at a 8 out of 10 and had difficulty turning to his side during resident care. Resident 2 was unable to recall the dates of the missing medication. Resident 2 stated, During the time he did not have lidocaine patch there were a couple of times his pain increased to 8 out of 10 on the pain scale. Resident 2 stated, he was able to tolerate the pain because he received other pain medication. During a review of Resident 2's Face Sheet (FS), the FS indicated, Resident 2 was admitted to the facility on [DATE]. Resident 2 had the following diagnosis related to pain: . fracture (break in the bone) of sixth cervical vertebra . fracture of left tibia (length of the bone below the knee and above the ankle) . During an interview on 2/7/23, at 11:00 a.m., with the DON, the DON stated the Licensed Nurses were to call the pharmacy right away to follow up on a refill order. The DON stated all resident medications documented on the MAR as unavailable should have been followed up with a call to the Medical Doctor (MD). The DON stated, she was unable to verify if the LN's called the pharmacy because there was no documentation. The DON stated, the LN ' s did not alert her of the unavailable medication for Resident 2. During a concurrent interview and record review, on 2/9/23, at 10:05 a.m., the ADON reviewed Resident 2's MAR dated 12/2022. The MAR indicated, . Lidocaine Patch 4% apply to lower back at 6:00 a.m. related to pain in thoracic spine (located in the upper and middle part of back). The ADON stated, he was responsible to reorder, stock and notify LNs of the availability of Over the Counter (OTC) medications for the residents such as Lidocaine patches. The ADON stated, he received 8 boxes of Lidocaine patches with 5 patches in each box for a total of a 40-day supply of patches on December 15, 2022. The ADON stated he placed one box of Lidocaine patches in the medication cart and put four boxes of Lidocaine patches in the medication room. The ADON stated, Resident 2 had a doctor's order to change patch daily. The ADON stated there were enough Lidocaine patches for Resident 2 until 1/24/23. The ADON stated, Resident 2 did not receive his Lidocaine patch for 12 days in the month of December 2022, even though Lidocaine patches were available. The ADON stated, the December 2022 MAR for Resident 2 showed a number 11 in the MAR box and LN initials. The ADON stated number 11 meant the medication was not available. The MAR indicated Lidocaine patches were marked unavailable and were not given to Resident 2 from December 15 to 20, 2022 and December 22 to 27, 2022. During a concurrent interview and record review on 2/9/2023, at 10:07 a.m., the ADON reviewed Resident 2's MAR dated 1/2023. The MAR indicated, . Lidocaine Patch 4% apply to lower back at 8:00 a.m.related to pain in thoracic spine. The ADON stated the January 2023 MAR for Resident 2 showed a number 11 in the MAR box with LN initials which indicates the medication was not available on those days. The ADON stated Resident 2 did not receive his Lidocaine Patch for 8 days in January 2023 even though the Lidocaine patches were available. The MAR indicated Lidocaine patches were marked unavailable and were not given on January 1, 5, 7, 8, 9, 11, 12, and January 21, 2023. The ADON stated, We should have monitored the ' Medication Not Available' documentation on MAR for no more than 3 missed doses and acted immediately. We failed to monitor and review the MAR for Resident 2. The ADON stated, the situation could have been much worse if the missed medications were a blood thinner or a blood pressure medication, that was not administered because LN did not know the medication was available and unaware of where to look for the medication. During a review of Resident 2's Care Plan (CP), dated 2/9/23, the CP indicated, . Administer pain medication as ordered . will not experience a decline in function related to pain . Will maintain adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress . During an interview on 2/9/23 at 11:00 a.m. with the ADON, the ADON stated, We should have asked LN 4 why she was not giving the Lidocaine Patch for Resident 2 when it was available. The ADON stated, the Lidocaine patches were available. The ADON stated, he communicated with the staff when he placed the boxes of Lidocaine patches in the medication room. The ADON stated, We are responsible to make sure residents get the ordered medications because we are management . We should have noticed the number of days Resident 2 was not receiving the medication . we are responsible for catching the medication errors. The ADON stated, there were no progress notes for all the missed doses. The ADON stated, there was a failure in communication by LN 4 and no available progress notes documented regarding the missed medications. The ADON stated the MD was not notified of the missed medication. During a telephone interview on 2/9/23 at 3:20 p.m., with LN 4, LN 4 stated she worked in December 2022 during the night shift. LN 4 stated, Resident 2 was scheduled for his Lidocaine Patches at 6:00 a.m. daily. LN 4 states Resident 2 also received Norco (medication used to treat moderate to severe pain). LN 4 stated, she documented in the MAR box as a 11 indicating Lidocaine Patch was not available. LN 4 stated, she was unable to find any Lidocaine patch in the medication room. LN 4 stated, I was under the assumption the medication was not here [in the facility]. LN 4 stated, she was busy and did not alert the DON or ADON about the unavailable medication. LN 4 stated, We should not let residents run out of their medications . I should have called the pharmacy, ADON or DON and MD, and I did not. LN 4 stated, she did not document in the progress notes about Resident 2 pain level or assess for pain. LVN 4 stated, it was important to have a complete and accurate pain assessment to include the level of pain, quality, region, severity, and time to have a trail to look back on and evaluate the underlying cause of the pain. During a concurrent observation, interview and record review on 2/9/23, at 4:00p.m., in the DON's office, the ADON brought in staff In-service documents. DON stated, in-services were immediately provided to the staff. A review of the facility's Lesson Plan on Pain In-service, indicated, . Pain In-Service . Identify appropriate assessments of pain and different scales of pain and how to apply them to patient situations . A review of the Lesson Plan on Pharmacy Procedures and Communications, indicated, . Know what a satellite pharmacy and how to request STAT medications . Notification to MD, DON, and ADON of missing medications . Charting and Progress notes . Pharmacy medications and Delivery Procedures . During a review of pharmacy policy titled Medication Ordering and Receiving from Pharmacy, dated 1/2022, the policy indicated, . Ordering medications from the dispensing Pharmacy . Medication orders are written on a medication order form provided by the pharmacy The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy . Reorder medication three to four days in advance of need, as directed by the pharmacy order and delivery schedule, to assure adequate supply is on hand .

Based on interview and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of five sampled residents (Resident 56) when Licensed Vocational Nurse (LVN) 1 did not assess Resident 56's complaints of pain and report of redness, swelling and warmth to left hip area which started in the morning (8 a.m.) of 2/4/22. This failure resulted in Resident 56 experiencing pain and suffering and not being sent out to the hospital for evaluation until the night (11 p.m.) of 2/4/22. Findings: During a review of Resident 56's Change in Condition Evaluation (COCE), dated 2/4/22, the COCE indicated, . Date:2/4/2022 17:40 [5:40 p.m.] . Pain (uncontrolled) . Skin evaluation . Other 16a. Specify other: left leg swelling . Pain evaluation 17. Does the resident have pain? . Yes . Reported to primacy care clinician . 2/4/2022 . 1530 . Recommendation . X-ray . During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical functioning level) assessment, dated 1/13/22, the MDS assessment indicated Resident 56's Brief Interview for Mental Status (BIMS - screening tool used in nursing home to assess cognition) assessment score was 13 out of 15, (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating no cognitive deficit. The MDS assessment Section G, dated 1/13/22, indicated, . A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture . 1. Self-Performance: . 3 [Extensive assistance (resident involved in activity staff provide weight-bearing support)] . 2. Support . 3 [Two+ persons physical assist] . B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . 3 [Extensive assistance] . 3 [Two+ persons physical assist] . Functional Limitation in Range of Motion . Coding: 1. Impairment on one side . A. Upper extremity (shoulder, elbow, wrist, hand) . Mobility Devices . C. Wheelchair . During a review of Resident 56's Core Analytics Lab [Laboratory] and Radiology, Patient Report, dated 2/4/2022, the report indicated, . Procedure . Hips, Bilat [Bilateral - both sides], W/ Pelvis . Findings: Pelvis and bilateral hips . active displaced fracture through the left femoral neck . IMPRESSION: Acute displaced fracture through the left femoral neck . During an interview on 2/10/22, at 9:38 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she was assigned to Resident 56 on 2/4/22 when Resident 56 complained of pain and discomfort on her left leg with movement. CNA 1 stated, Resident 56 was leaning on her side eating breakfast in bed. CNA 1 stated, Resident 56 complained of pain on her left leg when she (CNA 1) helped her (Resident 56) sit up straight in bed. CNA 1 stated, Resident 56 complained of pain and discomfort during her shift every time she (Resident 56) was moved and repositioned in bed. CNA 1 stated, she informed the LVN 1 when Resident 56 first complained of pain on the morning )7:30 a.m.) of 2/4/22. During a concurrent interview and record review on 2/10/22, at 9:56 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, she did not receive report about Resident 56's left leg pain from LVN 1 during change of shift (2:30 p.m. 2/4/22) report. LVN 2 stated, after the shift report, LVN 1 (am shift charge nurse) stated I forgot to tell you the Social Service Director (SSD) told me something about Resident 56's leg. LVN 2 stated, she went to check on Resident 56 after shift report. LVN 2 stated, . Her [Resident 56] legs were covered but I noticed the big bump over the left leg like a pillow. So, I uncovered her left leg and saw the left leg was twice the size, of the right leg . LVN 2 stated the left leg was swollen from the hip to the knee area. LVN 2 reviewed progress note dated 2/4/22, . Resident refused to work with physical therapy due to pain, writer [LVN 1] notified and went to assess resident, upon assessment resident left leg was swollen and resident complained of pain . During an interview on 2/10/22, at 10:30 a.m., with SSD, SSD stated, PTA (Physical Therapist Assistant) went to see her to report Resident 56 yelling out in her room. SSD stated, she went and talked to Resident 56 in her room. SSD stated, . She [Resident 56] asked me to move her leg and straighten her foot . SSD stated, she uncovered Resident 56's leg and saw her left leg was swollen, turned outward and was warm to the touch. SSD stated, she notified the charge nurse (LVN 1) right away (at around 1:15 p.m.) and reported what she observed on Resident 56. During a concurrent interview and record review on 2/10/22, at 11:10 a.m., with PTA, PTA reviewed Resident 56's Physical Therapy: Weekly TEN Details, dated 1/29/22 to 2/4/22, . Friday 2/4/2022 . Facilitated Pt [patient] in skilled interventions . Pt needed repositioning multiple times during Tx [treatment] activities secondary hip and knee pain at 6/10 with redness/warmth/swelling and RN [registered nurse] was notified. PTA stated, he went to see Resident 56 in her room before breakfast (7:45 a.m.) to set her up for therapy (on 2/4/22) and Resident 56 complained of discomfort. PTA stated, Resident 56's left leg was abducted (away from the right leg). PTA stated, when he started working on Resident 56 left leg, she complained of pain of 5 out of 10 (pain scale 0-10 and 10 is the highest) without him even touching the leg. PTA stated, Resident 56's pain increased to 6 out of 10 when her left leg was touched. PTA stated, he talked to the morning charge (LVN 1) nurse and asked if Resident 56 had a wound on her back side. PTA stated, . The charge nurse and I went to Resident 56 room and turned Resident 56 and when I grabbed her [Resident 56] left leg, it felt warm and with a little bit of redness . PTA stated, he compared the left leg with the right leg and the left leg was swollen, red and warm with complaints of discomfort with movement and touch. PTA stated, he told the charge nurse, . I think it is time to look into this because she had all the three indicators like pain, redness and swelling . PTA stated, the charge nurse said she was going to call the doctor. During a concurrent interview and record review on 2/10/22, at 1:58 p.m., with LVN 1, she stated she was the charge nurse for Resident 56 on 2/4/22, morning shift. LVN 1 stated, Resident 56 was her usual self. LVN 1 stated, Resident 56 only wanted cup of coffee during breakfast. LVN 1 stated, she remembered PTA kept going back to Resident 56's room but was not aware of the reason. LVN 1 stated, she did not recall any report of Resident 56 complaints of pain of the left leg during her shift from any staff (CNA, PTA, SSD or Night shift Nurse). LVN 1 stated, she went to Resident 56's room at 2:30 p.m. to do treatment on Resident 56 wound and observed her left leg bigger in size than usual compared to the right leg. LVN 1 stated, she tried calling the primary doctor towards the end of her shift but there was no answer. During an interview on 2/10/22, at 4:37 p.m., with CNA 2, CNA 2 stated, she worked on 2/4/22 (afternoon shift) and she took care of Resident 56. CNA 2 stated, she did not receive any report from the morning shift CNA or LVN 1 about Resident 56's complained of pain to her left leg. CNA 2 stated, between 9-9:30 p.m., the LVN 2 called her to assist in repositioning Resident 56 for the radiology technician to get an X-ray of resident's hip and leg. CNA 2 stated, as soon as Resident 56 was turned she noticed the left leg was swollen and was not straight. CNA 2 stated, Resident 56 complained of pain when turned and stated, ow, ow, ow repeatedly. CNA 2 stated, LVN 2 did not ask Resident 56 to rate the level of pain. During an interview on 2/11/22, at 8:39 a.m., with the Director of Nursing (DON), DON stated, there was no documentation indicating LVN 1 assessed the reported pain, redness and swelling of Resident 56's left leg. DON stated, she expected the nurses to address resident's pain and discomfort as soon as it was reported. During a review of the facility's policy and procedure (P&P) titled, Pain Management Guideline, undated, the P&P indicated, . To provide guidance for consistent assessment, management and documentation of pain in order to provide maximum comfort and enhanced quality of life . recognizing and reporting pain . assessing pain . Intervening to treat pain before the pain becomes severe .

**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 (used to treat psychosis - conditions that affect the mind, where there had been some loss of contact with reality) medication for four of five residents (Residents 4, 21, 20 and 52) when antipsychotic medications were prescribed and administered prior to determining the appropriate indications for use. The facility did not develop and implement non-pharmacologic (without the use of medications) interventions prior to physicians prescribing the use of anti-psychotic medications. Mental health professionals (psychologists and/or psychiatric providers) were not consistently consulted to accurately diagnose resident mental health illnesses and prior to the use of anti-psychotics. The anti-psychotics, once administered, were not appropriately monitored for negative effects. These failures resulted in the unnecessary use of olanzapine (used to treat mental disorders) for Resident 4 with the subsequent harm of experiencing difficulty swallowing, inability to take in adequate nutrition and a significant weight loss of 35 pounds in one month; and for Resident 21 the unnecessary use of quetiapine (used to treat schizophrenia [a condition that affects the persons ability to think, feel and behave clearly]), bipolar disorder (a condition associated with episodes of mood swings), and depression (condition associated with persistent loss of interest in activities, causing impairment in daily life) and the decrease of quality of life. All four residents had the potential 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 drug), 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 indigestion of anti-psychotics. Findings: 1. During a review of Resident 4's admission Record (AR), dated 2/9/22, the AR indicated Resident 4 is a [AGE] year old female who was admitted from an acute care hospital on 7/22/21 to the facility, whose diagnoses included Chronic Obstructive Pulmonary Disease (group of lung diseases that block airflow and make it difficult to breath), Anxiety Disorder, Schizophrenia, Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and Dementia (a condition characterized by impairment of at least two brain fictions, such as memory loss and judgement Other Diseases Classified Elsewhere with Behavioral Disturbance. A review of Resident 4's Medical Record (MR), the MR indicated Resident 4 had an order for Olanzapine. A review of the prescriber's (physician) order, dated 1/23/22, indicated the Resident had an order for Olanzapine Tablet 20 MG (milligrams - a unit of measure) Give 1 tablet by mouth one time a day for Manifested by threatening behaviors to self and others related to SCHIZOPHRENIA, UNSPECIFIED . During an observation, on 2/9/22 at 9:36 a.m., in Resident 4's room, Resident 4 was observed sleeping in her bed and did not awake when the door was knocked. During an observation, on 2/9/22 at 2:14 p.m., in Resident 4's room, Resident 4 was observed sleeping in her bed and did not awake when the door was knocked. During an observation, on 2/9/22 at 4:40 p.m., in Resident 4's room, Resident 4 was observed sleeping in her bed and did not awake when the door was knocked. During an interview on 2/9/22 at 2:19 p.m., with LVN 2, LVN 2 stated Resident 4 was not always sleeping when she first admitted to the facility. Now, she mostly sleeps, and this has been going on for about a month, since the start of the Olanzapine. During a concurrent interview and record review, on 2/9/22 at 2:36 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 4's MR dated 2/9/22 was reviewed. LVN 2 stated there was no documentation on the MR that Resident 4 had a history or diagnosis of schizophrenia. LVN 2 stated having an inappropriate diagnosis or medications could affect Resident 4's health and mental status. During a concurrent interview and record review, on 2/9/22 at 2:49 p.m., with LVN 2, Resident 4's MR, dated 2/9/22 was reviewed. LVN 2 stated she never saw Resident 4 hurt others or herself. LVN 2 stated she did not observe Resident 4 exhibiting behaviors of delusion (a belief or altered reality that is persistently held despite evidence) or hallucinations ( a perception of having seen, heard, touched, tasted or smelled something that was not actually there). LVN 2 stated the MR indicated Resident 4's starting dose was Olanzapine 20 mg. During a concurrent interview and record review on 2/9/22, at 3:20 p.m., with LVN 2, Resident 4's MR, dated 2/9/22 was reviewed. LVN 2 verified there was no documentation for non-pharmacological interventions or behavior monitoring prior to starting Olanzapine for Resident 4. LVN 2 stated medication was not best because of side effects especially at their [resident's] older age and better to start with non-pharmacological interventions. During a concurrent interview and record review on 2/9/22, at 3:25 p.m., with the Infection Preventionist (IP), Resident 4's MR, dated 2/9/22 was reviewed. IP stated he previously worked as a charge nurse prior to his IP position and familiar with Resident 4's behaviors. IP stated the Medical Doctor (MD) was doing his rounds in the facility on 1/24/22 and he told the MD that there was no diagnosis for Olanzapine. IP stated after reading the manifested behaviors [threatening behaviors to self and others] from the MR, MD wrote a diagnosis of schizophrenia for Olanzapine 20 mg. During a concurrent interview and record review on 2/9/22, at 4:14 p.m., with LVN 2, Resident 4's MR, dated 2/9/22 was reviewed. LVN 2 stated Resident 4 had a weight loss of 35 lbs (pounds, unit of measurement). LVN 2 stated Resident 4's weight on 2/4/22 was 155 lbs, previous weight on 1/5/22 was 190 lbs. During a concurrent interview and record review on 2/9/22, at 4:16 p.m., with LVN 2, Resident 4's IDT[interdisciplinary Team] Weight Note (IWN), dated 2/3/22 was reviewed. The IWN indicated, . Resident has significant wt [weight] loss in 1 month . Resident's intake at 35-57% average last 17 meals, intake continues to be low . LVN 2 stated Resident 4's food intake on 2/9/22 for breakfast and lunch was 0-25%. During a concurrent interview and record review on 2/10/22, at 10:47 a.m., with Speech Therapist (ST), Resident 4's MR, dated 2/10/22 was reviewed. ST stated on 2/1/22, an ST order was placed by the charge nurse that Resident 4 was having difficulty swallowing. ST acknowledged Resident 4 did not have a prior history of dysphagia (difficulty swallowing) or pneumonia. ST stated Resident 4 had a recent onset with difficult masticating (chewing) and pocketing (holding food inside the mouth without swallowing) and nursing reported decline in oral intake. ST stated, when I assessed her tongue and lips, she had little resistance meaning she had weakness in tongue and lips that made it difficult for her oral phase of swallowing which is chewing and pushing food front to back and keeping food in mouth . oral sensation issues, could not feel food in mouth. ST stated Resident 4 had received five treatments for dysphagia rehabilitation. ST stated choking can be a negative outcome, as well as malnutrition and weight loss and Resident 4's enjoyment of food could be affected. During a concurrent interview and record review on 2/10/22, at 11:46 a.m., with (Registered Dietician) RD, Resident 4's MR, dated 2/10/22 was reviewed. RD stated Resident 4 had a weight loss of 35 lbs. RD stated Resident 4's weight on 2/4/22 was 155 lbs, previous weight on 1/5/22 was 190 lbs. RD acknowledged Resident 4 was placed on Olanzapine on 1/23/22, with weight changes as well as dysphagia as a side effect. RD stated the IDT on 2/3/22 recommended 2.0 (type or kind) house supplement at 120 milliliters (ml - measurement of liquid volume) TID (three times a day) with med [medication] pass and weekly weight monitoring because Resident 4 had significant weight loss in 1 month, intake was low, and needed more help [verbal cueing and meal tray set-up] at mealtimes. During a concurrent interview and record review on 2/10/22, at 5:01 p.m., with LVN 9, Resident 4's Medication Administration Record (MAR), dated 2/10/22 was reviewed. The MAR indicated, . 1/1/22 - 1/31/22 . Olanzapine Table 20 MG Give 1 tablet by mouth one time a day for Manifested by threatening behaviors to self and others related to SCHIZOPHRENIA, UNSPECIFIED . Monitor Side Effects 1) Dystonia [involuntary muscle contractions that cause repetitive twisting movements]: torticollis (stiffness of neck); 2) Anti-cholinergic symptoms [such as] A. dry mouth, blurred vision, B. Constipation, urinary retention: 3) Hypotension [low blood pressure]; 4) Sedation/drowsiness; 5) Increased falls/dizziness; 6) Cardiac Abnormalities; 7) Anxiety/agitation; 9) Sweating/rashes; 10) Headache; 11) Urinary retention/hesitancy; 14) Psuedoparkinsonism-Cogwheel rigidity [stiffening of muscles and tremors] Bradykinesia [slow moment], Tremors; 15) Appetite change/weight change; 16) Insomnia; 17) Confusion; 29) None . Monitor every shift . Day . # [number of times per shift] . Eve (evening) . # . Night . # . [29 was coded 28 times] LVN stated the MAR for 2/1/22 to 2/10/22 indicated no appetite change or weight change. LVN stated the MAR was not accurate because Resident 4 had a weight loss of 35 lbs last month. During a concurrent interview and record review on 2/10/22, at 5:07 p.m., with LVN 9, Resident 4's MR, dated 2/10/22 was reviewed. LVN 9 stated the IDT recommendation on 2/3/22 to weigh weekly was not ordered and implemented. LVN 9 stated, Nurse should have gotten the order from MD. Whenever there is a significant change in weight, we monitor the weight for 4 weeks. A review of the facility's consultant psychologist notes for Resident 4 titled, Psychology Treatment Memorandum, dated 1/25/22, indicated, . Initial evaluation . Depression . start Lexapro [used to treat depression and generalized anxiety disorder] 10 mg qd [daily] . Moderate Dementia w/ [with] behaviors . start Aricept [used to treat confusion or dementia related to Alzheimer's, a progressive disease that destroys memory and other important mental functions] 5 mg qd after 1 month increased to 10 mg qd . Anxiety . During a telephone interview and record review on 2/14/22 at 10:29 a.m. with Consultant Psychologist (PSY), Resident 4's MR, dated 2/14/22 was reviewed. PSY stated he did not diagnose Resident 4 with Schizophrenia and was not aware Resident 4 had been diagnosed with schizophrenia. PSY stated he was not aware Resident 4 had been initiated on Olanzapine. PSY stated he saw Resident 4 on 1/25/22 for follow-up assessment related to diagnoses of anxiety, depression, and moderate dementia with behaviors. PSY stated Olanzapine 20 mg was not an appropriate initial dose. PSY stated he would normally start at 2.5 mg twice a day then gradually increase as needed. PSY stated the facility should have a review process before starting an antipsychotic medication. PSY stated the facility should consult with the psychologist or a mental health profession prior to starting an antipsychotic medication regimen. PSY stated Olanzapine could cause lethargy and lack of responsiveness, issues where the resident could become lethargic and not be able to eat. According to the manufacturer's package insert for Olanzapine adult dosing for Schizophrenia indicate, Initial: 5 mg once daily increasing to 10 mg once daily within several days or 10 mg once daily. Thereafter may increase dose based on response and tolerability in increments of 5 mg/day at intervals of 1 week up to 20 mg/day . During a telephone interview and record review on 2/14/22 at 12:38 p.m., with Consultant Pharmacist (CP), Resident 4's MR, dated 2/14/22 was reviewed. CP stated Olanzapine 20 mg BID (two times a day) was not an appropriate initial dose. CP stated there was no documentation in Resident 4's medical records that indicated Resident 4 received non-pharmacological interventions prior to initiation of olanzapine. CP stated it was important to use non-pharmacological interventions because the interventions can reduce the need for antipsychotics and reduce associated side effects of the medications. CP stated Olanzapine could cause lethargy, dry mouth, swallowing difficulty and weight loss. CP stated nursing should monitor Resident 4 for pseudo-parkinsonism and other adverse side effects of Olanzapine. During a concurrent interview and record review on 2/14/22 at 3:48 p.m., with Director of Nursing (DON), Resident 4's MR, dated 2/14/22 was reviewed. DON stated she does not know how Resident 4 got the schizophrenia diagnosis and could be based on what the nurses reported to the doctor. DON stated the facility should have a psychological evaluation to properly diagnose and determine if the behavior was psychological or dementia related. The DON stated non-pharmacological interventions and behavioral monitoring should be initiated prior to and during use of psychotropic medications. DON stated non-pharmacological interventions were necessary to make sure the facility tried other things [interventions] before initiating antipsychotics medication. During a concurrent interview and record review on 2/14/22 at 4:34 p.m., with DON, Resident 4's MR, dated 2/14/22 was reviewed. DON stated the facility did not follow the IDT recommendation for Resident 4 to conduct weekly weight for four weeks. DON stated it was not normal for a resident to lose 35 lbs in a short amount of time. DON stated if resident cannot swallow, behaviors could be more intense because the resident (Resident 4) was not getting the nutritional balance and had been continuously taking all her medications. During a concurrent interview and record review on 2/15/22 at 10:22 a.m., with the MD 2 and Administrator in Training (AIT), Resident 4's MR, dated 2/15/22 was reviewed. MD 2 stated Resident 4 diagnoses of schizophrenia came from the information he obtained from the nurses. MD 2 stated he prescribed a high dose of Olanzapine [20 mg daily] for Resident 4. MD 2 stated the initial dose should be 2.5 mg or 5 mg daily. MD 2 stated he agreed with the manufacturer specification to start Olanzapine at a lower dose. MD 2 stated that based on the DSM-5 (Diagnostic and Statical Manual of Mental Disorders, the standard used by mental health professionals in the United Stated to diagnose mental health disorder), the diagnosis of schizophrenia for Resident 4 was inappropriate, and should be changed or removed. MD stated there should be a clinical assessment for mental health diagnosis by a mental health professional, not just word of mouth from nurses. During a concurrent interview and record review on 2/15/22 at 10:22 a.m., with the AIT, Resident 4's MR, dated 2/15/22 was reviewed. AIT stated he was unable to find a documentation of Resident 4 having hallucinations and stated that non-pharmacological interventions were not attempted for Resident 4 before starting Olanzapine. During a concurrent interview and record review on 2/15/22 at 10:46 a.m., with the MD 2 and AIT, Resident 4's MR, dated 2/15/22 was reviewed. MD 2 stated non-pharmacological interventions should be attempted first before giving medications. MD 2 stated antipsychotic medication should be the last choice. MD 2 stated he was aware of the black box warning (the highest safety-related warning that medications can have assigned by the Food and Drug Administration) for Olanzapine. MD 2 stated patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death. MD 2 stated Resident 4's Olanzapine could cause sedation, resulting to swallowing difficulty. MD stated he would follow-up with the DON and titrate (slowly increase) the dose. According to the manufacturer's package insert for Olanzapine, the Boxed Warning indicates, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death . Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. According to the manufacturer's package insert, significant adverse reactions for Olanzapine include, extrapyramidal symptoms (EPS), also known as drug-induced movement disorders. Antipsychotics can cause 4 main EPS: Acute dystonia (repetitive body movements, drug-induced parkinsonism (a medical condition causing slowed movements, muscle stiffness, and a shuffling walk), akathisia (a state of agitation, distress, and restlessness), and tardive dyskinesia (a medical condition characterized by involuntary movements of the face). EPS presenting as dysphagia (difficulty in swallowing), esophageal dysmotility (a sensation that food is stuck in the throat or chest), or aspiration (accidental breathing in of food or fluid into the lungs) have also been reported with antipsychotics, which may not be recognized as EPS. 2. During a review of Resident 21's admission Record (AR), dated 2/8/22, the AR indicated Resident 21 was an [AGE] year old male who was admitted from an acute care hospital on 1/23/19 to the facility and readmitted to the facility on [DATE], whose diagnoses included unspecified dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) without behavioral disturbance, hyperlipidemia (high cholesterol), anxiety (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness), muscle weakness, history of falling, and unspecified psychosis (a mental condition causing the person to experience false beliefs, seeing or hearing things that others do not see or hear) not due to a substance or known physiological (deals with the normal functions of the human body and parts) condition. A review of Resident 21's Medical Record (MR), indicated Resident 21 had an order for quetiapine. A review of the prescriber's order, dated 6/18/20, indicated the Resident had an order for [Brand Name for Quetiapine] 50 mg (milligrams, unit of measurement) to be given twice a day for . UNSPECIFIED PSYCHOSIS NOT DUE TO SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION m/b [manifested by] delusional statements where he believes others belongings are his and is causing his emotional distress which effects [affects] his quality of life. A review of the medication order, dated 7/3/20, indicated Resident 21's quetiapine order was increased to 100 mg twice a day for . UNSPECIFIED PSYCHOSIS NOT DUE TO SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION m/b delusional statements where he believes others belongings are his and is causing his emotional distress which effects his quality of life. A review of the medication order, dated 9/23/20, indicated Resident 21's quetiapine order was increased to 200 mg twice a day for . UNSPECIFIED PSYCHOSIS NOT DUE TO SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION m/b delusional statements where he is agitated and wanting to go home. A review of the medication order, dated 12/14/21, indicated Resident 21's quetiapine order was increased to 200 mg three times a day for . UNSPECIFIED PSYCHOSIS NOT DUE TO SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION. During a concurrent interview and observation, on 2/9/22 at 9:35 a.m., with Resident 21, Resident 21 was seating on his wheelchair and looking out through the patio door. Resident 21 stated, I cannot even think, I am lost, I feel dead here, I want to go home. During a concurrent interview and record review, on 2/9/22 at 10:54 a.m., with Licensed Vocational Nurse (LVN) 8 and Medical Record Director (MRD), Resident 21's Medical Record (MR), dated 2/9/22 was reviewed. LVN 8 stated there was no documentation on the MR that Resident 21 had a history of hallucinations, delusions, incoherent (unclear or confusing) thoughts related to psychosis prior to the diagnosis of psychosis on 2/21/19. LVN 8 stated having an incorrect diagnosis could result to wrong medication. During a concurrent interview and record review on 2/9/22, at 11:27 a.m., with LVN 8, Resident 21's MR, dated 2/9/22 was reviewed. LVN 8 stated there was no documentation for non-pharmacological interventions attempted for Resident 21 before starting quetiapine. LVN 8 stated relating to the care of Resident 21, Before we jump into medications we have to see if they calm down, sometimes we don't need medications. During a concurrent interview and record review on 2/9/22, at 12:21 p.m., with LVN 8, Resident 21's MR, dated 2/9/22 was reviewed. LVN 8 was unable to find documented evidence of monitoring for hemoglobin (red blood cell protein, hb [hemoglobin - a red protein responsible for transporting oxygen in the blood]) A1C (blood sugar measurement) for 2021 and no AIMS (Abnormal Involuntary Movement Scale) baseline when Resident 21 was started on quetiapine. LVN 8 stated the most recent A1C was on 9/17/20. LVN 8 stated without the appropriate monitoring of blood sugar, Resident 21 could have medical complications. LVN 8 stated an abnormal involuntary movement is a side effect of quetiapine and should be monitored and reported immediately to the doctor if symptoms of abnormal movement occur. LVN 8 also stated she could not locate in the MR documented evidence of monitoring for pseudoparkinsonism (a medical condition characterized by slowed movements, muscle stiffness, and a shuffling walk), akathisia (a set of symptoms that include agitation, distress, and restlessness), and tardive dyskinesia (a medical condition characterized by involuntary movements of the face). LVN 8 stated, If abnormal movement was observed, will have to stop the medication and notify the doctor immediately. Review of Resident 21's Medication Administration Record (MAR) dated 2/1/22-2/15/22, indicated . [Quetiapine Brand Name] Tablet 200 MG (Quetiapine Fumarate) Give 200 mg by mouth three times a day related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION . Monitor Side Effects 1) Dystonia: torticollis (stiffness of neck); 2) Anti-cholinergic (used to control involuntary muscle movements) symptoms? A. dry mouth, blurred vision, b. Constipation, urinary retention: 3) Hypotension; 4) Sedation/drowsiness; 7) Anxiety/agitation; 8) Blurred vision; 9) Sweating/rashes; 10) Headache; 11) Urinary retention/hesitancy; 12) Weakness; 13) Hangover effects; 28) Other [other side effects]; 29) None [no behavior] every shift . Hours . Day . # [number of times per shift] . Eve (evening) . # . Night . # . The order did not include monitoring for pseudoparkinsonism, akathisia, and tardive dyskinesia. According to the manufacturer's package insert, significant adverse reactions for quetiapine include, extrapyramidal symptoms (EPS), also known as drug-induced movement disorders. Antipsychotics can cause 4 main EPS: Acute dystonia, drug-induced parkinsonism, akathisia, and tardive dyskinesia. During a concurrent interview and record review on 2/9/22, at 2:05 p.m., with LVN 8, Resident 21's MAR, dated 2/9/22 was reviewed. LVN 8 stated Resident 21 had 27 episodes of psychosis from 9/1/21 to 9/30/21, 23 episodes of psychosis from 10/1/21 to 10/31/21, and 15 episodes of psychosis from 11/1/2021 to 11/30/2021. LVN 8 stated Resident 21's quetiapine order was increased to 200 mg three times a day on 12/14/21. LVN 8 stated Resident 21's behavior decreased over the 3-month period [September 2021 to November 2021] and the quetiapine was increased on [DATE]. LVN 8 stated it does not make sense to increase the medication [Quetiapine] when behavior had decreased. During a concurrent interview and record review on 2/9/22, at 2:05 p.m., with LVN 8, Resident 21's Progress Notes (PN), dated 12/13/21 was reviewed. The PN indicated, . 12/13/21 at 2:47 p.m., Resident was very calm and quiet up in his chair with good tolerance, sleep and ate when meals came but otherwise very quiet . No behaviors . 12/14/21 at 2:01 p.m., Resident was awake this am eating breakfast this am and did well no c/o [complain of] any pain or discomfort. He was up this am [meaning morning] was quiet and calm no behaviors at this time . 12/14/21 at 3:26 p.m., Resident has been lethargic [lack of energy] most of the time, at time he is awake and eats but lethargic most of the time. He has behaviors only in the evening. [ medical director (MD)] was here today and he was notified about resident being more lethargic and sleepier. See new orders. He was notified [Consultant Psychologist (PSY)], had placed him on this med see new changes. [name of wife] wife called via phone and notified and agree with orders . LVN 8 stated it does not make sense to increase the medication [quetiapine] when behavior had decreased from the previous months. LVN 8 stated increasing the medications could increase the side effects including the risk for fall, injury, and lethargy. During a concurrent interview and record review on 2/9/22, at 2:13 p.m., with LVN 2, Resident 21's MAR, dated 2/9/22 was reviewed. The MAR indicated, . 9/1/2021-9/30/2021 . Monitor for episodes of Psychosis manifested by believing others are trying to hurt him and he has been kidnapped. Every shift related to UNSPECIFIED PSYCHOSIS . Day . # [number of times per shift] . Eve (evening) . # . Night . # . [total 27] . 10/1/2021-10/31/2021 . Day . # [number of times per shift] . Eve (evening) . # . Night . # . [total 23] . 11/1/21-11/30/21 . Day . # [number of times per shift] . Eve (evening) . # . Night . # . [total 15] . LVN 2 stated Resident 21's behavior decreased over the 3-month period [September 2021 to November 2021] and the quetiapine was increased on [DATE]. LVN 2 stated it was not appropriate to increase the dose of quetiapine when behavior had decreased. During a telephone interview and concurrent record review on 2/14/22 at 10:03 a.m., with PSY, Resident 21's MR, dated 2/14/22 was reviewed. PSY stated he was not aware Resident 21's behavior decreased over the 3-month period [September 2021 to November 2021]. PSY stated he relied on the lead nurse for the summary of behaviors [monthly monitoring of behaviors]. PSY stated he increased the dosing of Resident 21's Quetiapine based on the information he received from the nurse. PSY stated if the behavior was decreasing it does not warrant an increase in dose of quetiapine. PSY stated he was not aware of any attempted GDR [gradual dose reduction] with Quetiapine. PSY stated he was not aware that quetiapine was for short-term use [for psychosis]. According to the manufacturer's package insert for quetiapine, adult dosing for psychosis associated with dementia indicated, For short-term adjunctive [added second to another treatment] use while addressing underlying cause(s) if severe symptoms . Immediate release: Oral: Initial: 15 mg at bedtime; may increase dose gradually (e.g.[meaning for example], weekly) based on response and tolerability up to 75 mg twice daily . During a telephone interview and record review on 2/14/22 at 11:39 a.m., with Consultant Pharmacist (CP), Resident 21's MR, dated 2/14/22 was reviewed. CP stated quetiapine was primarily used for managing schizophrenia (chronic and severe mental disorder that affects the way a person thinks, acts, expresses emotions, perceives reality, and relates to others) or adjunct to depression. The CP stated the unspecified psychosis was a vague diagnosis and does not match the indications for use. CP stated the Quetiapine order should have been clarified when it was first ordered by the attending physician. CP stated unspecified psychosis was not an FDA indication for quetiapine. CP stated there was no documentation in Resident 21's medical records that indicated Resident 21 received non-pharmacological (non-drug approach) interventions prior to initiation of quetiapine. CP stated it was important to reduce the necessity for use of antipsychotics because of their side effects. CP stated by using non-pharmacological interventions, this strategy could reduce the need for antipsychotic or eliminate its use even though that was rare. According to the manufacturer's package insert for quetiapine, Elderly patients have an increased risk of adverse effects to antipsychotics. In light of this risk, and relative to their small beneficial effect in the treatment of dementia-related psychosis and behavioral disorders, patients should be evaluated for possible reversible causes before being started on an antipsychotic. Nonpharmacologic interventions should be tried before initiating an antipsychotic. During a telephone interview and record review on 2/14/22 at 12:20 p.m., with CP, Resident 21's MR, dated 2/14/22 was reviewed. CP stated no AIMS test (monitoring tool used to measure involuntary movement) was done at baseline for Resident 21. CP stated he requested the two previous DONs (Director of Nursing) to conduct AIMS test in 9/2021 and 11/2021, and both were not done. CP stated baseline AIMS was important, serving as a benchmark for monitoring adverse side effects of antipsychotics. CP stated he requested a GDR for quetiapine in October 2021 and November 2021 because of no behaviors noted. CP stated the provider declined the GDR recommendation since no clinical justification was given. CP stated the GDR was important because resident behavior can be controlled in a lower dose or no drug at all and could reduce side effects of drugs, drug-drug interactions, and drug-disease interactions. CP acknowledged nursing did not monitor for symptoms of pseudoparkinsonism, akathisia and tardive dyskinesia as side effects of Quetiapine and stated nursing is expected to monitor those symptoms. According to the manufacturer's package insert (specific information about the drug) for quetiapine, frequency of monitoring indicates, . monitoring parameter hbA1C . frequency of monitoring . annually . monitoring parameter tardive dyskinesia . at least annually or every 6 months if high risk. During a concurrent interview and record review on 2/14/22 at 3:06 p.m., with the DON, Resident 21's MR, dated 2/14/22 was reviewed. DON stated she did not find any indication or any behaviors in Resident 21's MR that would support the diagnosis of psychosis. DON stated the quetiapine [200 mg three times a day] dose was inappropriate and did not know why the attending physician wrote the quetiapine order. DON stated no AIMS test was completed, no Hb A1C for 2021, behavior and side effects monitoring were inadequate. The DON stated nonpharmacological interventions were not attempted prior to initiating quetiapine. DON stated baseline AIMS was important to monitor for pseudoparkinson, akathisia, and tardive dyskinesia. DON stated nursing staff should monitor for side effects and ensure resident was free from adverse reaction. The DON stated non-pharmacological interventions and behavioral monitoring should be initiated prior to and during use of psychotropic medications. DON stated non-pharmacological interventions were necessary to make sure the facility tried other things [interventions] before initiating antipsychotics medication. DON stated she could not find GDR document and physician