**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and a review of the facility's policy titled Abuse Investigation and Reporting, the facility failed to report to the State Survey Agency (SA) a fall with major injury as required within two hours and in a timely manner for one of 46 sampled residents (R) (R9.) Findings Include:Review of the policy titled Abuse Investigation and Reporting, revised July 2017, section Reporting, documented 2. Alleged violations of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. TWO (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty- four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.Review of the Electronic Medical Record (EMR) revealed resident R9 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Alzheimer's disease with late onset, unspecified dementia, unspecified severity, with other behavioral disturbance, unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with routine healing and repeated falls.Review of R9's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00, which indicates R9 has severe cognitive impairment. Section GG, functional status, revealed R9 has no impairments with upper and lower body extremities but benefits from the use of wheelchair. With self-care, R9 is dependent in all areas with the exception of eating, requiring setup/clean up assistance. Mobility R9 requires partial moderate assistance in all areas attempted.Review of the Care Area Assessment (CAA) on the significant change, MDS documented no significant change. MDS was completed.Review of R9's care plan dated 7/29/2025 indicated a problem of an alteration in musculoskeletal status r/t fracture of the left hip. Interventions included, but not limited to, anticipate and meet needs, be sure call light is within reach, and respond promptly to all requests for assistance. A review of the Facility Incident Report Form submitted to the state on 7/27/2025, revealed type of incident: NH (Nursing Home) Only: witnessed fall with major injury with no alleged abuse. Date and time of incident: 7/26/2025 at 5:30 pm. Details of incident: On 7/26/2025 at approximately 5:30 pm, resident returned via wheelchair from the dining room and was sitting at the lobby area watching tv(television), in front of nurses desk. Resident was observed to rise from her wheelchair and immediately fall to the floor. Resident fell on left side. Staff immediately assessed resident and contacted Medical Director (MD) and family. Injury: Yes. Left femur per hospital.Interview on 7/31/2025 at 3:02 pm with Registered Nurse Supervisor (RN) SS revealed that he did not witness R9's fall. However, when he was called into the common area outside of his office, he saw R9 lying on her left side on the floor. RN SS stated he got on the ground to make sure she was not bleeding and completed checks (around 5:00 pm or 6:00 pm). RN SS then revealed that he instructed two staff members to return R9 to bed after assisting R9 off the ground. RN SS revealed that he called the MD, who ordered x-rays for R9, and she was given pain medication. RN SS stated that the primary nurse received a call from the mobile x-rays [NAME], stating they would not be available on [7/26/2025] but would be available at the facility on [7/27/2025]. RN SS revealed that on 7/27/2025, he called the MD around 2:00 pm to request that R9 be sent to the Emergency Department (ER) for evaluation, to which the MD agreed. R9 left the facility around 2:40 pm on 7/27/2025 for the local ER.Interview on 7/31/2025 at 5:54 pm with the Administrator; she stated that if this is a reportable incident, it should have been reported within 2 hours.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Hand Hygiene and Handling Clean Linen, the facility failed to ensure proper infection control practices were followed during observations of dining and clean laundry pass. This deficient practice had the potential to increase the risk of the spread of infections due to cross-contamination. The facility census was 74. Findings include: Review of the facility policy titled “Hand Hygiene,” dated 5/1/2025, revealed the “Policy” section stated, “All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff.” The “Policy Explanation and Compliance Guidelines” section included, “1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.”Review of the facility policy title, Handling Clean Linen, dated 5/1/2025, revealed the “Policy Explanation and Compliance Guidelines” section included, “ … 6. Carry clean linen with clean hands away from your body. …” 1. Observations on 7/31/2025 from 11:58 am to 12:12 pm, of dining in the dining room, revealed that Dietary Aide OO was passing meal trays to multiple residents without performing hand hygiene between the tray passes. Further observation revealed that Dietary Aide OO opened a trash can with her hand and served drinks to residents without performing hand hygiene between tasks. In an interview on 7/31/2025 at 12:20 pm, Dietary Aide OO stated that she did not know that she should perform hand hygiene between resident tray passes or after touching dirty objects until this date. In an interview on 7/31/2025 at 12:55 pm, the Dietary Manager revealed that he expected dietary aides to perform hand hygiene between each resident tray pass. 2. Observations on 7/31/2025 at 2:35 pm revealed that Housekeeper HH entered and exited multiple resident rooms while delivering clean clothing and placing items inside the residents' closets without performing hand hygiene between resident rooms. Observations on 7/31/2025 at 2:36 pm revealed that Housekeeper II entered and exited multiple resident rooms while delivering clean clothing and placing items inside the residents' closets without performing hand hygiene at any point between resident rooms. In an interview on 7/31/2025 at 2:47 pm, Housekeeper HH confirmed that she did not perform hand hygiene after entering and exiting each resident's room, and stated should have. In an interview on 7/31/2025 at 2:50 pm, Housekeeper II confirmed that he did not perform hand hygiene after entering and exiting each resident's room, and stated he was uncertain as to when he should be performing hand hygiene. In an interview on 7/312025 at 3:16 pm, the Director of Nursing (DON) revealed the expectation was for all staff to perform hand hygiene before and after entering each resident's room, including housekeeping staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and review of the facility policy titled Abuse Investigation and Reporting, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime (staff to resident verbal abuse) in accordance with section 1150B of the Act and failed to report the allegation of verbal abuse to the State Survey Agency (SSA) for one resident (R) (R52) of two residents reviewed for abuse. These failures had the potential to contribute to further verbal abuse and possible psychosocial harm for R52. Findings include: Review of the facility's Abuse Investigation and Reporting policy, revised July 2017, Reporting section revealed All alleged violations involving abuse, neglect, exploitation, or mistreatment . will be reported by the facility Administrator, or his/her designee to the following persons or agencies: The State licensing/certification agency responsible for surveying/licensing the facility . [and] Law enforcement officials . An alleged violation of abuse, neglect, exploitation or mistreatment . will be reported immediately, but not later than: Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. Review of R52's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses including depression, anxiety, insomnia, cognitive-communication deficit, and trigeminal neuralgia (a type of chronic pain disorder that involves sudden attacks of severe facial pain). Review of R52's Annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/22/2023 and located in the MDS tab of the EMR, revealed she scored 11 of 15 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. She was able to make herself understood and understand others, exhibited mild symptoms of depression, and did not exhibit behavioral symptoms. During an interview on 3/11/2024 at 9:54 am, R52 stated certified nurse aide (CNA) 11 was mean as hell and had said mean things to her. R52 stated that CNA11 told her if she rang the call bell or asked for help, the CNA would make her sit up all night in the wheelchair. R52 stated she prayed each day that CNA11 was not working and stated, In a way, I'm afraid of her because I believe she would do something to me if she got the chance. R52 stated she had reported this allegation to the staff, but CNA11 continued to work with her. R52 stated the alleged CNA was a white woman. During an interview on 3/11/2024 at 3:40 pm, the Administrator, who served as the facility's abuse coordinator, stated R52 had not reported the allegation and she was unaware of the resident's concern. During an interview on 3/12/2024 at 12:20 pm, the Administrator stated she found a Complaint Form in the Facility Concerns and Grievances binder addressing R52's allegation of verbal abuse by CNA11. The Administrator stated that R52 reported the allegation on 1/5/2024. At that time, R52 reported a short, white CNA had told her she would be left up in her wheelchair all night if she did not stop calling for help with the call light. The Administrator stated when she looked at the facts that R52 reported and spoke with the resident's roommate (who she stated was cognitively intact and who reported she had not seen anyone being abusive toward R52), the Administrator determined that the facility did not have a staff person that fit the description provided by R52 (in particular, CNA11 was Black and there were no white staff members working on the evening/night in question). The Administrator added that she met with R52 and her roommate again on 3/11/2024 regarding the allegation and R52 had changed the staff description to a tall, white female instead of a short, white female that she reported back in January. The Administrator stated the allegation of verbal abuse was not reported to the SSA or law enforcement because the allegation could not be substantiated. Review of R52's Complaint Form, dated 1/5/2024 and provided on paper in the Facility Concerns and Grievances binder, revealed, Resident told Activities Director that a staff member had been rude to her. Activities Director informed Administrator. Administrator went to the resident to inquire of the situation. Resident stated a white woman, short in height, on the 11p - 7a [night] shift told her she would have to stay in her chair all night if she did not quit calling [for help]. Administrator checked schedule and staff does not have a white CNA on that shift, nor the 3p -11p [evening] shift. Administrator asked resident if it could have been other staff members and inquired of each staff member by name. Resident denied those staff members. Resident claimed roommate had witnessed the event. Soc. Ser. [Social Services] Director questioned roommate who denied the event took place while she was in the room. Resident had traumatic event of losing her best friend and roomate [sic] recently. Staff will continue to check in on resident and assure her that the events are not (or are) taking place . Was complaint confirmed? No The completion date on the form was 1/8/2024. During an interview on 3/14/2024 at 2:35 pm, the Administrator stated she considered R52's allegation an allegation of verbal abuse. She stated abuse allegations needed to be reported immediately, at least within two hours, to the SSA and law enforcement. The Administrator stated, however, that she reported only allegations where there was probable cause, and if there was no probable cause, she completed a Complaint Form but did not report the allegation. The Administrator confirmed this allegation had not been reported as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled Medication Ordering and Receiving from Pharmacy, the facility failed to ensure a routine drug was provided as ordered for one resident (R) (R60) of five residents reviewed for unnecessary medications. The failure to administer an ordered antipsychotic medication had the potential to cause increased behavioral symptoms and psychosocial harm for R60. Findings include: Review of the undated Medication Ordering and Receiving from Pharmacy policy revealed, Medications and related products are received from the dispensing pharmacy on a timely basis . Reorder medications at least 3 days in advance of need to assure an adequate supply is on hand . New medications . will be delivered with the regular delivery on the same day . A licensed nurse . promptly reports discrepancies and omissions to the issuing pharmacy by calling the pharmacy the next morning with any wrong, extra, or missing medications. Review of R60's Profile tab of the electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with behavioral disturbance, encephalopathy, psychotic disorder with delusions, depression, and anxiety. Review of R60's Significant Change of Status Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/9/2024 and located in the MDS tab of the EMR, revealed she scored two of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R60 had mild symptoms of depression and no behavioral symptoms. Review of R60's Care Plan, dated 11/27/2023 and located in the Care Plan tab of the EMR, revealed, The resident has a behavior problem r/t [related to] yells out [and] confusion. Declines to eat at times. Yells out. Delusional. Wandering into rooms, combative toward staff. Crying episodes. Declines meds. Removes clothing, briefs. Removes oxygen. Places self onto fall mat often and is noted as a behavior vs [versus] a fall. Plays in BM [bowel movement]. The approaches included, Administer medications as ordered. Review of R60's Orders tab of the EMR revealed an order for Seroquel (an antipsychotic medication), 25 milligrams (mg) every evening for psychotic disorder with delusions, that originated on 1/16/2024. Review of R60's March 2024 Medication Administration Record, located under the Reports section of the EMR, revealed she did not receive the scheduled dose of Seroquel, 25 mg in the evening from 3/1/2024 through 3/13/2024, with the exceptions of 3/1/2024, 3/4/2024, 3/6/2024, 3/9/2024, and 3/10/2024. However, staff confirmed the Seroquel was not given on those dates; it was signed out as given in error (cross-reference F842: Medical Record). Review of R60's Orders - Administration Notes located in the Progress Notes tab of the EMR revealed on 3/2/2024, 3/3/2024, 3/5/2024, 3/7/2024, 3/8/2024, 3/11/2024, 3/12/2024, and 3/13/2024, the 25mg dose of Seroquel was not available for administration. During an interview on 3/14/2024 at 3:37 pm, Licensed Practical Nurse (LPN) 3 stated R60's Seroquel had been unavailable for the month of March, as it had not yet come in from the pharmacy. LPN3 stated she did not know why the medication had not yet been received, as several shipments had come in from the pharmacy during the month. She stated she needed to call the pharmacy and follow up. During an interview on 3/14/2024 at 3:59 pm, the Director of Nursing (DON) stated she had just learned from LPN3 about R60's missing Seroquel and had called the pharmacy. She stated the medication was on its way. The DON stated the medication had been reordered on 2/28/2024 and the pharmacy reported it was a mistake on their end; however, the facility staff should have followed up with the pharmacy and used the facility's backup medication supply until the pharmacy delivered the medication. The DON stated R60 did not receive her 25mg Seroquel dose at all in March 2024; on the days it was documented as given it was actually not given. The DON stated she educated staff on the importance of providing all ordered doses of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled Medication Ordering and Receiving from Pharmacy, the facility failed to ensure accurate documentation in the medical record of medications administered for one resident (R) (R60) of five residents reviewed for unnecessary medications. The failure to accurately document medication administration had the potential to cause unnecessary antipsychotic medication use, and associated adverse side effects, for R60. Findings include: Review of the undated Medication Ordering and Receiving from Pharmacy policy revealed, The facility maintains accurate records of medication order and receipt. Review of R60's Profile tab of the electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with behavioral disturbance, encephalopathy, psychotic disorder with delusions, depression, and anxiety. Review of R60's Significant Change of Status Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/9/2024 and located in the MDS tab of the EMR, revealed she scored two of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R60 had mild symptoms of depression and no behavioral symptoms. Review of R60's Care Plan, dated 11/27/2023 and located in the Care Plan tab of the EMR, revealed, The resident has a behavior problem r/t [related to] yells out [and] confusion. Declines to eat at times. Yells out. Delusional. Wandering into rooms, combative toward staff. Crying episodes. Declines meds. Removes clothing, briefs. Removes oxygen. Places self onto fall mat often and is noted as a behavior vs [versus] a fall. Plays in BM [bowel movement]. The approaches included, Administer medications as ordered. Review of R60's Orders tab of the EMR revealed an order for Seroquel (an antipsychotic medication), 25 milligrams (mg) every evening for psychotic disorder with delusions, which originated on 1/16/2024. Review of R60's March 2024 Medication Administration Record (MAR), located under the Reports section of the EMR, revealed she did not receive the scheduled dose of Seroquel, 25 mg in the evening from 3/1/2024 through 3/13/2024, with the exceptions of 3/1/2024, 3/4/2024, 3/6/2024, 3/09/2024, and 3/10/2024. On 3/1/2024, Licensed Practical Nurse (LPN) 3 documented administration of the Seroquel dose, and LPN5 documented administration on 3/4/2024, 3/6/2024,3/09/2024, and 3/10/2024. Review of R60's Orders - Administration Notes located in the Progress Notes tab of the EMR revealed on 3/2/2024, 3/3/2024, 3/5/2024, 3/7/2024, 3/8/2024, 3/11/2024, 3/12/2024, and 3/13/2024, the 25mg dose of Seroquel was not available for administration. During an interview on 3/14/2024 at 3:37 pm, LPN3 stated R60's Seroquel had been unavailable for the month of March, as it had not yet come in from the pharmacy. During an interview on 3/14/2024 at 3:59 pm, the Director of Nursing (DON) stated medication had been reordered on 2/28/2024 but was not received from the pharmacy. The DON stated R60 did not receive her 25mg Seroquel dose at all in March 2024; on the days it was documented as given it was actually not given. During an interview on 3/14/2024 at 4:14 pm, LPN5 stated R60's 25mg dose of Seroquel had not been available during March 2024 and she had documented its administration in error on the MAR. LPN5 stated she needed to be more careful when documenting medication administration, as it was important to accurately reflect the medications R60 received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, review of facility documents titled How to Safely Remove PPE Example 2, and PPE Guidelines for Routine Care, and review of facility policies titled Personal Protective Equipment - Using Face Masks, Personal Protective Equipment - Using Gloves, and Personal Protective Equipment - Using Gowns, the facility failed to ensure proper use of personal protective equipment (PPE) in the implementation of transmission-based precautions, for one of one resident (R) (R42) reviewed for transmission-based precautions. Findings include: Review of the facility policy titled Personal Protective Equipment - Using Face Masks, revised September 2010 indicated Removing the Mask, 4. Discard the mask into the designated waste receptable inside the room. Review of the facility policy titled Personal Protective Equipment - Using Gloves, revised September 2010 indicated Removing Gloves, 4. Discard the glove into the designated waste receptable inside the room. Review of the facility policy titled Personal Protective Equipment - Using Gowns, revised September 2010 indicated After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room. Review of the document titled How to Safely Remove PPE Example 2, indicated Remove all PPE before exiting the patient room except a respirator if worn. Review of the document titled PPE Guidelines for Routine Care, indicated to remove gown and gloves inside the resident's room. These documents were posted on R42's door and were the posting HK 13 referred to in her interview. Review of R42's undated admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R42 was admitted to the facility on [DATE]. R42's diagnoses included Coronavirus disease 2019 (COVID-19) dated 3/12/2024. Review of an admission Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 2/9/2024 revealed a Brief Interview of Mental Status score (BIMS) of 15 out of 15 indicating R42 was cognitively intact. The MDS indicated R42 was dependent on staff for toileting hygiene, bathing, and personal hygiene. Review of the most recent Comprehensive Care Plan, located in the resident EMR under the Care Plan tab, initiated 3/11/2024, indicated R42 tested positive for COVID-19 with interventions to assist resident with activities of daily living, encourage to use clean hygiene techniques to avoid cross-contamination, and isolation per protocol. Review of active Orders located in the EMR under the Orders tab revealed the following order dated 3/12/2024: Paxlovid oral tablet therapy. Review of a Progress Note located in the EMR under the Progress Notes tab revealed a note dated 3/11/2024 which indicated R42 tested positive for COVID-19. During an observation on 3/13/2024 at 10:24 am, Housekeeper (HK) 13 was observed donning Personal Protective Equipment (PPE) (gown, gloves, face shield, mask) and entered R42's room with a certified nurse aid. A few minutes later HK13 was observed still wearing full PPE exiting R42's room to retrieve supplies off the housekeeping cart two different times, once to grab a trash bag and a second time to grab a mop. HK13's housekeeping cart was parked approximately five to six feet from R42's door. The third time, HK13 stepped out of the room with all PPE still on and began to remove her gown outside of the resident room in front of R42's door, adjacent to the PPE storage bin holding PPE supplies. During an interview on 3/13/2024 at 10:27 am, HK 13 stated she was trained to take all items she needed to clean inside the resident room with her after donning PPE and then dispose of PPE in the large trash bin inside the resident room before exiting. HK13 pointed to the trash bin located inside R42's room. HK 13 also referred to a sign on R42's door which outlined the instructions for donning and doffing PPE. HK13 stated she cleaned R42's room daily.HK13 confirmed she exited R42's room while still wearing PPE. During an interview on 3/13/2024 at 10:40 am, Certified Nurse Aide (CNA) 7 stated for a resident in isolation for transmission-based precautions staff received in-servicing and that included nursing staff, housekeeping staff, and maintenance staff because housekeepers and maintenance staff have to go in the resident rooms too. CNA7 stated they were educated to dispose of PPE in the resident's room before exiting the room. During an observation on 3/14/2024 at 10:09 am, CNA6 stepped out of R42's room to the middle of the hallway calling out for CNA7. CNA6 walked approximately 10-12 feet out of R42's room wearing a yellow gown, gloves, mask, and face shield. R42's door was open and R42 was observed lying in bed. A few minutes later CNA7 knocked on R42's door and asked CNA6 what she needed and returned with a bag of briefs. During an interview on 3/14/2024 at 10:10 am, CNA6 stated yes, that she had just come out of R42's room because she needed CNA7 to get her something for care. When asked if she should be stepping out of the room with her PPE on CNA6 stated no, that is why she was looking for CNA7. During an interview on 3/14/2024 at 1:18 pm, the Infection Preventionist (IP) stated gown, gloves, and face shield should be discarded in the room trash receptacle and the N95 mask should be removed after exiting the room. All staff attended infection prevention in-services for donning and doffing, including housekeeping staff, and should know to dispose of everything except the mask before they exit the resident room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R17's undated admission Record, located in the Profile tab of the EMR, revealed R17 was admitted to the facility on [DATE]. R17's diagnoses included adjustment disorder with mixed anxiety and depressed mood. Review of an admission MDS, located in the EMR under the MDS tab, with an ARD of 2/16/2024 indicated R17 had a BIMS) of 13 indicating R17 was cognitively intact. Review of the most recent Comprehensive Care Plan, located in the resident EMR under the Care Plan tab, initiated 3/11/2024, indicated R17 used antidepressant medication related to depression with the goal The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. The interventions for this focus included Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Observe/document/report PRN adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in activities of daily living (ADL) ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt loss, n/v, dry mouth, dry eyes. Review of R17's active Orders located in the EMR under the Orders tab revealed an order dated 3/6/2024 for Remeron (an antidepressant medication) oral tablet 15 mg - Give 1 tablet by mouth at bedtime. Review of R17's active orders did not indicate an order to monitor or document side effects or effectiveness every shift. Review of R17's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for March 2024, located in the EMR under the Orders tab in Reports revealed no evidence of monitoring for Remeron side effects or efficacy. Review of the Task Sheet located in the EMR under the Tasks tab revealed only behavior monitoring. The behaviors included frequent crying, repeats movements, yelling/screaming, kicking/hitting, pushing, grabbing, pinching, biting, wandering, abusive language, threatening behavior, sexually inappropriate, and rejection of care. The Task Sheet indicated resident had none of those symptoms listed. There was no evidence of Remeron side effect or efficacy monitoring. Review of R17's last 30 day's Progress Notes located in the EMR under the Progress Notes tab revealed no notes related to Remeron side effects and efficacy monitoring every shift. During an interview on 3/14/2024 at 11:07 am LPN 1 stated if a resident's medication requires monitoring it would be on the MAR. She stated it would be entered as an order so that it prompts staff to enter the monitoring on the MAR. LPN 1 stated it would be similar to pain medication monitoring where the MAR prompts staff to go back into the MAR to enter the new pain level after the resident receives pain medication. LPN 1 reviewed R17's MAR and confirmed the MAR did not include a prompt to monitor for side effects or efficacy, only to monitor for behaviors. LPN 1 clicked on the behavior monitoring and it did not include antidepressant monitoring. LPN 1 stated if monitoring was part of the care plan, then it should also be on the MAR. LPN 1 reviewed R17's MAR and confirmed it did not have any required monitoring for Remeron. During an interview on 3/14/2024 at 12:04 pm the Director of Nursing (DON) stated for side effect monitoring if staff coded that a resident had a side effect by entering 9 - it should prompt staff to enter a related progress note. During an interview on 3/14/2024 at 12:14 pm, the DON stated R17 was prescribed Remeron and there should be an order to monitor effectiveness and side effects so that it shows on the MAR. Based on record reviews, staff interviews, and review of the facility policy titled Psychotropic Medication Use, the facility failed to ensure three residents (R) (R26, R60, and R17) of five residents reviewed for unnecessary medication were being monitored for behaviors while taking psychotropic medications. Findings Include: Review of the facility policy titled Psychotropic Medication Use, dated July 2022 revealed 3. Psychotropic medication management includes: d. adequate monitoring for efficacy and adverse consequences; and, e. preventing, identifying and responding to adverse consequences. 1. Review of R26's Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy, dementia with behavioral disturbance, depression, and psychotic disorder with hallucinations. Review of R26's Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/13/2023, revealed he scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. He exhibited minor symptoms of depression and no behavioral symptoms. R26 used antipsychotic and antidepressant medications. Review of R26's Care Plan, dated 8/9/2022 and located in the Care Plan tab of the EMR, revealed, The resident uses psychotropic medications r/t [related to] behavior management. Dx. [diagnosis of] dementia with behaviors. Aggressive, verbally abusive toward others. The approaches included: Administer psychotropic medications as ordered by physician. Observe for side effects and effectiveness Q-shift . Consult with pharmacy, MD [physician] to consider dosage reduction when clinically appropriate at least quarterly . [and] Observe/document/report . behavior symptoms not usual to the person. Review of R26's Orders tab of the EMR revealed an order, dated 2/22/2023, for Zyprexa (an antipsychotic medication), 5mg at bedtime for dementia with behaviors. The Orders tab also included an order, dated 7/29/2022, for Behaviors - monitor for the following: (specify) itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression [sic], refusing care. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift. Review of R26's March 2024 Medication Administration Record (MAR), located in the Reports section of the EMR, revealed the above order for behavior monitoring every shift; however, from 3/1/2024 through 3/13/2024, there were checkmarks rather than 'Y' or 'N' documented. There were no associated codes documented on the MAR and there were no associated Progress Notes to indicate any behaviors were exhibited. The March 2024 MAR also included space to document Yes or No to behaviors corresponding to the evening administration of Zyprexa. A Yes was documented on 3/3/2024, 3/4/2024, 3/5/2024, 3/6/2024, 3/7/2024, 3/8/2024, 3/9/2024, and 3/10/2024. These behaviors were not reflected in the behavior monitoring done every shift on the MAR. Review of R26's Orders - Administration Notes related to Zyprexa administration, located in the Progress Notes tab of the EMR, revealed Was a behavior observed? was answered Yes from 03/03/24 through 03/10/24. However, there were no notes written to indicate the type of behaviors, potential causes, or interventions. During an interview on 3/14/2024 at 11:35 am, Registered Nurse (RN) 1 stated R26 could be short with the staff when frustrated but did not exhibit any behavioral symptoms. During an interview on 3/14/2024 at 11:36 am, Licensed Practical Nurse (LPN) 4 stated R26 stayed in bed quite a bit and did not exhibit any problematic behavioral symptoms. She stated his mood could be up and down at times. LPN4 stated staff monitored behaviors by entering a 'Y' or 'N' on the MAR, and if a behavior was observed, there should be documentation in the Progress Notes indicating the type of behavior and any additional information including potential causes and interventions. During an interview on 3/14/2024 at 12:42 pm, the Director of Nursing (DON) stated if a behavior was observed, there should be a Progress Note to explain the type and extent of the behavior, the situation, potential causes, and interventions. She stated whenever a Yes was documented on MAR, a corresponding note should explain the type of behavior. The DON stated the behavior documentation would be reviewed when collaborating with the physician and pharmacist on deciding to conduct gradual dose reductions. During an interview on 3/14/2024 at 1:10 pm, the DON stated the current system for behavior monitoring could be confusing, as there was more than one place to record whether a behavior occurred and there were not always associated Progress Notes to explain the behavior. 2. Review of R60's Profile tab of the EMR revealed she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease with behavioral disturbance, encephalopathy, psychotic disorder with delusions, depression, and anxiety. Review of R60's Significant Change of Status MDS assessment, with an ARD of 2/9/2024 and located in the MDS tab of the EMR, revealed she scored two of 15 on the BIMS, indicating severely impaired cognition. R60 had mild symptoms of depression and no behavioral symptoms. The resident used antipsychotic, antidepressant, and anti-anxiety medications and a gradual dose reduction had not been attempted. Review of R60's Care Plan, dated 11/27/2023 and located in the Care Plan tab of the EMR, revealed, The resident has a behavior problem r/t [related to] yells out [and] confusion. Declines to eat at times. Yells out. Delusional. Wandering into rooms, combative toward staff. Crying episodes. Declines meds. Removes clothing, briefs. Removes oxygen. Places self onto fall mat often and is noted as a behavior vs [versus] a fall. Plays in BM [bowel movement]. The approaches included: Administer medications as ordered. Monitor/document for side effects and effectiveness . If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident . [and] Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Review of R60's Orders tab of the EMR revealed an order for Seroquel (an antipsychotic medication), 25 mg every evening for psychotic disorder with delusions, dated 1/16/2024 and an order for Seroquel, 50 mg every morning for psychotic disorder with delusions, dated 2/28/2024. The Orders tab also included an order, dated 11/20/2023, for, Behaviors - monitor for the following: (specify) itching, picking at skin, restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression [sic], refusing care. Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings every shift. Review of R60's March 2024 MAR, located in the Reports section of the EMR, revealed the above order for behavior monitoring every shift; however, from 3/1/2024 through 3/13/2024, there were checkmarks rather than 'Y' or 'N' documented except for a code '9' documented on the evening shift on 3/2/2024, the evening shift on 3/12/2024, and the day shift on 3/13/2024. According to the MAR, the code '9' indicated, Other/See Progress Notes. Review of the Progress Notes tab in the EMR revealed corresponding behaviors of yelling out and trying to get out of bed were documented in the notes on these three dates. The March 2024 MAR also included space to document Yes or No to behaviors corresponding to the evening administration of Seroquel. A Yes was documented on 3/4/2024, 3/6/2024, 3/8/2024, 3/9/2024, and 3/10/2024. These behaviors were not reflected in the behavior monitoring done every shift on the MAR. Review of R60's Orders - Administration Notes related to Seroquel administration, located in the Progress Notes tab of the EMR, revealed on 3/4/2024, 3/06/2024, 3/9/2024, and 3/10/2023, the question, Was a behavior observed? was answered Yes. However, there were no notes written to indicate the type of behaviors, potential causes, or interventions. During an interview on 3/14/2024 at 11:36 am, LPN4 stated staff monitored behaviors by entering a 'Y' or 'N' on the MAR, and if a behavior was observed, there should be documentation in the Progress Notes indicating the type of behavior and any additional information including potential causes and interventions. During an interview on 3/14/2024 at 12:42 pm, the DON stated if a behavior was observed, there should be a Progress Note to explain the type and extent of the behavior, the situation and potential causes, and interventions. She stated whenever a Yes was documented on MAR, a corresponding note should explain the type of behavior. The DON stated the behavior documentation would be reviewed when collaborating with the physician and pharmacist on deciding to conduct gradual dose reductions. During an interview on 3/14/2024 at 1:10 pm, the DON stated the current system for behavior monitoring could be confusing, as there was more than one place to record whether a behavior occurred and there were not always associated Progress Notes to explain the behavior. During an interview on 3/14/2024 at 1:20 pm, Certified Nurse Aide (CNA) 8 stated R60 exhibited behaviors of crawling out of bed onto the floor mats and would yell out or cry out frequently. She stated the nurses monitored residents' behaviors.