**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed the to report alleged violations of misappropriation of property to the proper authorities, including the police and the State Survey and Certification Agency, in accordance with state law for one (#97) of three residents reviewed for missing property out of 19 sample residents. Specifically, the facility failed to report an allegation of misappropriation of property to the State Agency, adult protective services or the local police when Resident #97 reported he was missing $750.00 from his wallet. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 11/7/24 at 8:39 a.m. The policy revealed the facility did not condone resident abuse and should take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends or any other individuals. Residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included, but was not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Misappropriation of resident property was defined as the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Misappropriation included, but was not limited to, theft, fraud and financial exploitation. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source was suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting could be completed verbally or in writing. Immediately was defined as within two hours of an allegation involving abuse or resulting in serious bodily injury or within 24 hours of an allegation that did not involve abuse or result in serious bodily injury. Notification was also made to the following persons and agencies within the time frames defined by regulation or statute: the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, adult protective services (where state law provides jurisdiction in long-term care), law enforcement officials (for all abuse allegations), the resident's attending physician and the medical director (when necessary). In addition to an investigation by the police department, the facility would conduct an internal investigation. While the investigation was ongoing, the alleged assailant would have interventions implemented to help ensure the safety of the alleged victim as well as other residents. The investigation would include interviewing any staff members, residents or family members who may have knowledge of the incident. Results of all investigations would be reported to the administrator or his or her designated representative and to other officials in accordance with state law, including to the State Survey Agency, within 5 (five) working days of the incident, and if the alleged violation was verified, appropriate corrective action would be taken. II. Resident #97 A. Resident status Resident #97, age greater than 65, was admitted on [DATE] and discharged home on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included motorcycle injury in a traffic accident, traumatic subdural hemorrhage (brain injury), fracture of thoracic vertebra, multiple right side rib fractures, fracture of the neck, atrial fibrillation and quadriplegia. The 8/11/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interview Resident #97 was interviewed by phone on 11/4/24 at 11:39 a.m. Resident #97 said he had $750.00 in a wallet that was placed in a drawer in his room during his stay at the facility. He said he did not carry the wallet with him. He said someone would have had to go into the drawer to retrieve the money from his wallet. He said he did not have a lock box in his room. He said he knew he should not have kept that much money in his room at the facility, however, he said he had needed the money to pay some bills. He said a friend came to help him pay his bills after he was discharged from the facility and that was when he discovered the money was missing. Resident #97 said after he discovered the money was missing from his wallet, he called the facility to report it. C. Record review The Acknowledgement Form admission Packet signed by Resident #97 on 8/7/23 revealed the facility could not guarantee the safety of personal property and the facility was not responsible for the loss of personal property except as required by applicable federal and state law. If a resident would like insurance protection covering the loss of property, it was the resident's responsibility to obtain such insurance. It was the right of each resident to manage his or her own financial affairs. If the resident was unable to manage their personal affairs or if a resident did not want to manage their personal affairs themselves, the facility had a resident trust fund account that the facility would manage in accordance with federal and state laws. If the resident chose to participate in this program, the monies would be kept in an interest bearing account that was separate from the facility's funds, and the resident would receive quarterly statements of the account. A care plan for discharge, initiated on 5/24/23, revealed the resident was planning to discharge to another state where he independently lived alone. The plan did not reveal the resident had mentioned any missing monies. A review of Resident #97's personal property inventory sheet, dated 8/7/23, did not reveal the resident had $750.00 dollars when he was admitted to the facility. The resident initialed the sheet. The resident's Discharge summary, dated [DATE] at 10:27 a.m., did not reveal the resident had discussed any missing monies with staff members. The summary revealed the resident said he had no questions or concerns at the time of his discharge from the facility. The multidisciplinary care conference, dated 10/18/23 at 1:10 p.m., revealed a discussion took place regarding Resident #97's overall progress with skilled therapy services and discharge planning. There was no documentation that the resident had reported any missing money. A complaint/concerns report, dated 10/25/23 at 10:15 a.m., revealed the resident called the facility that morning (10/25/23) and said the facility stole $750.00 dollars from him. The report documented that the resident said he was discharged to his home in another state and he wanted to talk with the NHA today (10/25/23). The Misappropriation of Property Occurrence/Abuse form was provided by the NHA on 11/6/24 at 5:49 p.m. The form revealed the first known date and time of Resident #97's allegation of missing $750.00 was 10/25/23 at 10:00 a.m. The form further revealed the resident was discharged on 10/23/23. The Misappropriation of Property Occurrence/Abuse form included interviews of residents and staff. None of the residents who were interviewed reported any concerns of missing money or property. None of the staff members who were interviewed reported any knowledge of Resident #97 having $750.00 in his wallet during his stay at the facility. Review of the State Survey Agency database on 11/4/24 failed to show evidence the facility had reported the alleged misappropriation of property involving Resident #97 to the State Agency as required. D. Staff interview The NHA was interviewed on 11/6/24 at 4:07 p.m. The NHA said on 10/25/23 at 10:15 a.m., Resident #97 called the facility and said someone had stolen $750.00 dollars from him. The NHA said the resident said he had the money when he arrived at the facility. The NHA said 10/25/23 was the first time she was made aware of the missing money. The NHA said Resident #97 told her that he did not know the $750.00 dollars was missing until he arrived at his home after being discharged from the facility. The NHA said the resident's belongings inventory sheet did not reveal he had $750.00 dollars when he entered the facility. The NHA said during care conferences and during the discharge meetings, Resident #97 never said he was missing any money. The NHA said neither she nor any of her staff had seen the money the resident referred to. She said she did a thorough misappropriation of property investigation and none of the interviewed staff had ever seen the resident's money and none of the interviewed residents had any missing items. The NHA said Resident #97 did not have a roommate during his stay at the facility. The NHA said upon admission, Resident #97 was offered a lock box for his room, however the resident refused. The NHA said the resident was offered the use of a trust account to put any money he had into the fund and the resident refused. The NHA said she called the previous facility that the resident resided at and was informed that they had no record of the $750.00 dollars and the resident did not have a trust account with that facility. The NHA said, to her knowledge, the money did not exist because she was unable to find anyone who had seen the money. The NHA said while Resident #97 resided in the facility, the resident never said he had missing money. The NHA said she was not able to prove that Resident #97 did or did not have the money at the facility. The NHA said the facility completed an investigation after Resident #97 called and reported the missing money, however, she said she did not report the incident to the State Agency occurrence reporting portal because it did not meet the reporting criteria.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards in one of one medication storage rooms. Specifically, the facility failed to: -Maintain the emergency medication kit with medications that had not expired; and, -Ensure the emergency medication kit did not have two different expiration dates on individual packages which were prepared by the pharmacy. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy, revised February 2023, was provided by the director of nursing (DON) on 11/6/24 at 3:35 p.m. The policy read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The medication label includes at a minimum the medication name, prescribed dose, strength, expiration date, when applicable, resident's name, route of administration and appropriate instructions and precautions. II. Observations and interview On 11/5/24 at 9:06 a.m. the medication storage room was observed with registered nurse (RN) #1. The emergency medication kit had a yellow label on the outside of the kit which revealed there were medications within the kit that expired in October 2024. The kit contained approximately 100 individually packaged medications that had been prepared by the pharmacy. The following items were found in the emergency kit: -Two individual pill packages of ciprofloxacin (an antibiotic medication) 250 milligrams (mg) with an expiration date on the label of 3/31/23. A second expiration date of September 2024 was also printed on the label. -Three packages of levofloxacin an antibiotic medication) 250 mg all revealed an expiration date on the labels of October 2024. There were no additional expiration dates on the packages. RN #1 said the medications were expired and she did not know which expiration date was accurate for the medication labeled with two expiration dates. She said expired medications could be less effective if they were given to residents. Additional findings found in the emergency medication kit included the following: -Two packages of ciprofloxacin 500 mg with two expiration dates on the label of 10/1/24 and March 2025. -One package of levofloxacin 500 mg with two expiration dates of October 2024 and 9/6/25. -Three packages of albuterol sulfate inhalation solution (medication used to treat respiratory conditions) 0.083%, 2.5 mg with one expiration date on the label of 8/22/24 and an expiration date on the package of January 2025. -Seven packages of metoprolol (a blood pressure medication) 25 mg with two expiration dates on the label of 10/1/24 and March 2026. -One package of Cefuroxime (an antibiotic medication) 500 mg with two expiration dates on the label of 10/1/24 and March 2025. -One package of cephalexin (an antibiotic medication) 250 mg with two expiration dates on the label of 8/22/24 and December 2024. -Ten packages of clindamycin (an antibiotic medication) 150 mg with two expiration dates on the label of 4/26/24 and August 2025. RN #1 said the package labels were confusing because there were two expiration dates on the labels. She said she was not certain if the medications had expired or not because one of the expiration dates was in the past and the other expiration date was dated in the future. III. Staff interviews The pharmacist (PH) was interviewed on 11/5/24 at 9:40 a.m. The PH said the pharmacy department had a list of all medications in the facility's emergency medication kit and a member of the pharmacy team checked the kit monthly for medications that were due to expire. The PH said the pharmacy department was not onsite at the facility during the month of October 2024 to review the expiration dates in the emergency medication kit. The PH said the three levofloxacin 250 mg medication packages and the two ciprofloxacin 250 mg medication packages were expired and had been overlooked when they last checked the kit in September 2024. The PH said the pharmacy and the facility were responsible for checking expiration dates of medications within the emergency kit. The PH said the accurate expiration date was the later of the two dates on each of the packages. She said the earlier expiration date on the packages reflected an automatically generated date when the labels were created. The PH said the two expiration dates on one medication label could create confusion for the nursing staff when they checked expiration dates. She said she would relabel the medications with one expiration date to eliminate any confusion. The DON was interviewed on 11/5/24 at 10:30 am. The DON said it was confusing to have two different expiration dates on the emergency medication kit medication packages and she did not know which expiration date was correct. The DON was interviewed again on 11/7/24 at 9:57 a.m. The DON said the pharmacy had the responsibility of reviewing emergency medication kit expiration dates once per month. The DON said nursing staff should check the expiration dates on medications that were removed from the kit for use or if nursing staff added any replacement medications to the kit received from the pharmacy. IV. Facility follow up On 11/5/24 at 1:20 p.m. the DON provided an example of new emergency medication kit labels made by the PH which contained only one expiration date. The DON said all of the labels on the emergency kit medications had been corrected to one expiration date (during the survey). On 11/7/24 at 9:57 a.m., the DON said the pharmacy was going to begin removing medications from the emergency kit one month prior to the expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for one (#19) of two residents reviewed for use of psychotropic medication out of 21 sample residents. Specifically, the facility failed to for Resident #19: -Ensure staff identified triggers for the the resident's anxiety disorder; -Develop a resident-centered plan of care for generalized anxiety disorder; -Ensure staff monitored and document the resident for her response to antidepressant medication and its effectiveness; and, -Ensure staff monitor and document the resident for adverse reactions to dual antidepressant therapy. Findings include: I. Facility policy The Psychopharmacological policy, dated 3/10/23, was received on 6/21/23 from the nursing home administrator (NHA), which read in pertinent part: The licensed nurse or designee will document any known targeted behaviors and potential interventions on the [NAME] (an abbreviated care directive). This will help to assure certified nursing assistants receive communication related to the initial plan of care. The admission record is reviewed within 72-hours of a resident's admission by the interdisciplinary team to assure admission orders and applicable policy and procedures have been initiated. This review will include the use of psychopharmacological drugs, appropriate diagnosis. -The interdisciplinary team will proceed to care planning for the use of psychopharmacological drugs, and the Care Plan for psychopharmacological medications will be implemented. -The care plan will include the resident's focus and target behaviors for the medication. Realistic and measurable goals will be utilized and approaches will include alternatives to psychopharmacological drug use. -The plan of care must include behavior interventions and medication monitoring/dosage reduction if appropriate. Consideration should be given to potential underlying causes of the behavior symptoms to assure appropriate treatment. Monitoring: Licensed nurses and additional staff will monitor and document any targeted behaviors that occur. These behaviors will be documented on one or more of the following: Point of Care, Progress Notes, or on a Risk Management Incident Report. II. Resident status Resident #38, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), diagnoses included hypertension, dementia, anxiety and chronic obstructive pulmonary disease. The 5/17/23 minimum data set (MDS) assessment revealed the resident had cognitive impairment with a score of 12 out of 15 on the brief interview for mental status (BIMS) assessment. The resident required assistance from one staff member for bed mobility, walking in the room and corridor, locomotion on and off the unit, dressing, personal hygiene, required extensive assistance from one staff member for toileting and was independent with eating. The resident's behavior assessment documented no behavioral symptoms or behaviors. III. Resident interview and observation Resident #38 was interviewed on 6/21/23 at 9:17 a.m. The resident was sitting on the edge of her bed and was leaning forwards with her face down on the bed. She said she bent over to think and calm herself. Resident #19 said she had bad anxiety. She said that since she had been admitted to the facility she had not had anxiety relief and said that when she felt anxious she would forget to breathe. She said she felt staff did not understand that she needed extra time and explanations because her anxiety could worsen and made her uncomfortable. The resident said that her anxiety increased when it was noisy in her room, when she did not know what was going on during the day, when she felt lonely and when she had the feeling that she had shortness of breath. She said she had to self-adjust the flow rate on her oxygen concentrator when her anxiety worsened. The resident said no staff had asked her if her anxiety was better or worse, she did not know what medications she was taking for her anxiety and did not know that she was taking two antidepressant medications. The resident said she felt unhappy that medications had been changed and that a medication that had worked well for her anxiety (Alprazolam) was stopped and she did not know why and wished to take it again. III. Record review A review of the June 2023 computerized physician orders (CPO) revealed the resident was prescribed the following antidepressant psychotropic medications: -Paxil, 30 mg once a day, prescribed for generalized anxiety disorder with a start date of 5/11/23; -Doxepin 50 mg once a day, prescribed generalized anxiety disorder with a start date of 5/11/23. The physician progress note dated 5/12/23 recorded the resident had dementia with anxiety and chronic history of memory issues. -The physician note did not include information regarding the treatment plan for the status of the resident's anxiety. The resident's care plan dated 6/20/23 (during the survey) revealed the resident was prescribed antidepressant medication (Paxil) for generalized anxiety disorder. -The resident-centered care plan omitted the use of the second antidepressant, Doxepin. The resident's care plan focus area for use of antidepressant medications included: Goal: The resident will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included: -Administer antidepressant medications as ordered by physician; -Monitor/document side effects and effectiveness every shift; -Black box warning: monitor closely for worsening and emergence of suicidal thoughts and behaviors; -Monitor/document/report prn adverse reactions to antidepressant therapy: -Change in behavior/mood/cognition; -Hallucinations/delusions; -Social isolation; -Suicidal thoughts; and, -Withdrawal. -The CPO failed to include orders to monitor the resident for side effects, effectiveness and/or adverse reactions to antidepressant therapy. The care plan failed to identify goals or interventions specific to the management of the resident's anxiety disorder to include identifying, recognizing the onset, presence of anxiety. It failed to include the history of her anxiety, and factors which precipitate or exacerbate anxiety. On 6/21/23 at 10:05 a.m., the director of nursing (DON) provided a Behavior/Interventions Monthly Flow Record paper copy of monitoring behavior for the use of Paxil. The pre-printed form, flow record directed the nurse to document resident statements of feeling anxious. -The flow record did not include resident centered goals or interventions to monitor triggers for anxiety. The flow record documented the following anxiety episodes: 6/4/23 two episodes. The resident was provided an activity and the nurse document that was effective. 6/8/23 two episodes. The resident was effectively redirected. 6/11/23 one episode. The resident was provided fluids, which was effective. 6/16/23 two episodes. The resident was provided food and fluids, which was effective. 6/18/23 one episode. The resident was provided food, which was effective. -The flow record did not correlate with the resident's statement on 6/21/23 that her anxiety had not been relieved since her admission to the facility. The DON was unable to locate care plan documentation that included monitoring for antidepressant effectiveness or that focused on the resident's need for anxiety management. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/21/23 at 9:30 a.m. The CNA said she knew the resident had anxiety and noticed sometimes it was difficult for the resident to breathe at times. The CNA said that she had assisted the resident with placing her oxygen tubing and was not aware if the resident had self-adjusted the oxygen flow rate. The CNA acknowledged she was unaware what specifically caused the resident anxiety but she noticed the resident needed her oxygen when the humidity in the building was high. Registered nurse (RN) #1 was interviewed on 6/21/23 at 9:38 a.m. She said tracking and monitoring was documented in the resident's electronic health record specifically on the medication administration record. The RN was unable to locate tracking or monitoring physician orders or documentation specific monitoring for the resident's anxiety or antidepressant therapy. The RN said the tracking information might be in the director of nurses (DON) office. The assistant director of nursing (ADON) and the DON were interviewed together on 6/21/23 at 9:55 a.m. They said the nursing staff monitored residents prescribed psychotropic medications and documented the monitoring in the resident's electronic health record specifically on the medication administration record. The ADON and DON were unable to locate antidepressant medication monitoring for the resident. The DON said monitoring results were helpful for the physician to determine effectiveness of medication therapy. The DON said that when a resident was admitted , the interdisciplinary team (IDT) determined what monitoring was necessary and then nursing would obtain physician orders for monitoring.