Based on observation, interview and record review the facility failed to ensure a resident was free from unnecessary psychotropic medications for 1 of 3 residents (R4) reviewed for medications in a sample of 3. This failure resulted in R4 sustaining a fall due to a loss of balance, resulting in a hip fracture requiring surgical intervention. Findings include: R4's admission Record documents an admission date of 3/28/2025 and includes diagnoses of unspecified dementia, unspecified severity without behavioral disturbances, psychotic disturbances, mood disturbance, anxiety disorder, major depressive disorder, single episode, unspecified and glaucoma. R4's MDS (Minimum Data Set) dated 4/4/2025 documents a BIMS (Brief Interview for Mental Status) score of 7 indicating that R4 has severe cognitive impairment. Section GG documents R4 requires supervision or touching assistance with mobility. R4 requires supervision or touching assistance with ability to walk 10feet, 50 feet with 2 turns, and 150 feet once standing. R4 is independent to roll left to right. R4 requires supervision or touching assistance with sit to lying position changes, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer. R4's Fall Risk Evaluation dated 4/3/2025 at 8:34PM Category: NA, Level of Consciousness/mental state: Alert (oriented x3) , History of falls past 3 months: No falls in past 3 months, Ambulation/elimination status: Ambulatory/ continent, Vision status: Adequate with or without glasses, Gait/balance: Gait/balance normal, systolic blood pressure: no noted drop in blood pressure between lying and standing, Medications: none of these medications taken currently or within 7 days, Resident has had a change in medication or change in dosage in the past 5 days (Not checked), Predisposing disease: None present. R4's Care Plan documents a focus area of, I am risk for falls Gait/balance problems. Initiation date of 3/31/25. Interventions include anticipate and meet my needs initiated 3/31/25, walk with resident if she keeps pacing assist to chair with activity, initiated 4/3/25. R4's Care Plan documents another focus area of, Resident requires use of Box Warning Medications. Initiation date of 3/28/25. Goal: No injury or adverse effect related to medication usage. Interventions include: administer black box medications as ordered by medical doctor (MD), see Physician order sheet. Assess for adverse side effects, document and report to MD. Behavior tracking in place for psychotropic medications and reviewed per facility protocol. Labs as ordered by physician to monitor efficacy of medications. Medication list reviewed routinely with resident and /or resident representative/ Power of Attorney of Healthcare, Pharmacy consultant review medications use and potential side effects. Resident medications are to be reviewed monthly and as needed by pharmacist and physician. Teach about side effects of medications with family member/responsible party. Verbal consent received before initiation of any new or increased psychotropic medications and consents updated per facility protocol. R4's Care Plan also documents a focus area, I use anti-anxiety medications Anxiety disorder. Initiated 3/28/25. Interventions include: I am taking Anti-anxiety meds which are associated with an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, falls, broken hips and legs. Monitor FREQ (frequently) for safety. Date Initiated 3/28/25. 1. R4's Order Recap Report with a print date of 5/21/22 documents the following orders: Xanax (Benzodiazepines) 0.5 mg (milligrams), give every 12 hours PRN (as needed) for anxiety/agitation with a start date of 3/28/2025 (admission date) and an end date of 5/6/25. R4's March, April, and May 2025 Medication Administration Record (MAR) documents that R4 received 4 doses of the PRN Xanax from the time period of 3/28/2025 through 5/6/2025 on 4/7/2025 at 10:22PM, 4/21/2025 at 7:11PM, 4/28/2025 at 9:18PM, and 4/30/2025 at 7:53PM. The same Order Recap Report documents an order for Xanax 0.5 mg give 1 tablet by mouth two times a day related to anxiety with a start date of 5/6/25 and an end date of 5/8/25 and an order for Xanax 0.5 mg give 1 tablet by mouth three times a day related to anxiety with a start date of 5/8/25 and an end date of 5/16/25. R4's Progress Note dated 5/6/2025 at 2:12PM, authored by V3 (Licensed Practical Nurse), documents alarm went off this morning (at) 630 (6:30AM) and resident had left the property, I followed her to make sure she didn't get hurt but when I called the police and rehab resident took off and could not be found, resident was found about 3 hours later, taken to (name of local hospital) for eval then brought back to facility and stated she was going to leave again. A document titled Police Department Incident Report, date reported 5/6/2025 at 6:56:44 via wire phone documents Incident missing elderly woman at (Name of local street). Dispatched at 7:22:30 AM, [NAME] was deployed at 8:45:04, R4 located at 9:10:13 AM in garage right behind local business, called ambulance. R4's Progress Note dated 5/6/25 at 5:00PM, authored by V2 (Director of Nursing), documents Spoke with V20 (Physician) regarding resident's anxiety. New orders received for 0.5 mg Xanax BID (twice a day). Spoke with family and obtained consent for this medication. Family stated they thought this was a good idea and was very pleased with today's outcome offering praise to the staff. On 5/7/2025 at 1:58PM, R4 was observed ambulating with an assistive device of a cane. At that time R4 was with V13 (Activity Aide) who stated she is the one on one for R4 today. V13 was asked if R4 always used a cane. V13 stated no but R4 stated her foot hurt. R4 was asked what was hurting and R4 stated my right foot is really hurting. R4's Progress Note dated 5/7/25 at 2:22PM, authored by V10 (Licensed Practical Nurse), documents Resident stated her right foot is hurting, I called (V20) and left VM (voicemail). Waiting for response. R4's Progress Note dated 5/7/25 at 7:27PM, authored by V19 (Regional Clinical Director), documents X-ray results reviewed to resident's right foot and right ankle and all results are negative for any acute fractures. MD and POA (Power of Attorney) both updated of results. 2. R4's Order Recap Report with a print date of 5/21/25 documents an order for Risperidone (Antipsychotic) Oral Tablet give 1 mg by mouth one time only related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety for 1 day with a start date of 5/8/25 and an end date of 5/8/25. R4's Progress Note dated 5/8/25 at 8:39AM, authored by V2, documents Spoke with family regarding residents exit seeking behavior and calling family all hours of the night. Family requested to call (V20). (V20) notified and one time dose of risperidone 1 mg to be given at this time. Resident will be monitored closely for any adverse effects and (V20) will be called this afternoon. R4's May Medication Administration Record (MAR) documents a 1 on 5/8/25 for the Risperidone 1mg order. The Chart Codes/Follow Up Codes on the MAR documents that a 1 indicates refused. On 5/15/2025 at 1:54AM, V10 (Licensed Practical Nurse) stated that on 5/8/2025 R4 did take her one-time dose of Risperidone. V10 stated on 5/8/2025, she crushed the Risperidone and mixed it in water so R4 would take the medication, but R4 still refused. V10 stated she marked refused on the Medication Administration Record. V10 stated R4 did finally take the Risperidone around 2:00PM with convincing by the family and a police officer. V10 stated she forgot to go back and document on the Medication Administration Record that R4 did actually take the Risperidone. On 5/8/2025 at 10:20AM, R4 was observed in a wheelchair with V13 by her side. V13 stated she has R4 in a wheelchair due to R4 having unsteady balance and almost falling. V13 stated she was doing the one to one with R4. R4 was asked how her foot pain was and R4 stated, It doesn't even hurt anymore. R4 was asked if it hurt when she walked on it and R4 stated, No not at all. On 5/8/2025 at 11:45AM, observed R4 sitting at the nurse's station with V15 (family member) and V22 (Power of Attorney). V15 was trying to talk R4 into taking her medication. V22 stated the medication was Risperidone. R4 stated I am not taking that medication; I am a nurse, and you all are not doing that to me. On 5/8/2025 at 1:40PM, R4 was observed at the nurse's station with V15 and V22 present with another person whom V13 identified at this time as a cop that is friends with V22. V13 said that R4 likes cops so he is trying to talk (R4) into taking the rest of that medication. On 5/8/2025 at 2:00PM, V2 (Director of Nursing/DON) and V19 (Regional Clinical Director) were sitting in a front office and V2 stated, We have (R4) on Xanax now and gave Risperdal for the anxiety and elopement attempts. V2 was asked what diagnosis R4 had for the Risperidone and V2 stated Dementia. V2 stated we don't know what else to do to keep R4 from eloping again. On 5/8/25 at 2:10PM, V13 stated, She took the medication for the cop so she must trust cops. On 5/8/2025 at 2:40PM, R4 was observed sitting at the dining room table in a wheelchair. R4 was sitting with V13. R4 appeared sluggish with her eyes halfway open. V13 stated at this time that R4 is unsafe for ambulation due to being unsteady on her feet. R4's Progress Note dated 5/8/25 at 2:50PM, authored by V2, documents Spoke with (V20) regarding Risperidone. Risperidone DC'd (discontinued) and new order obtained for Xanax 0.5 mg TID (three times a day). Family is aware. There are no further Progress Note entries for R4 on 5/8/25 and 5/9/25. On 5/8/2025 at 3:00PM, V13 stated R4 is on medications, and she is sort of out of it. At that time R4 was sitting in a wheelchair in the dining room with increased confusion noted and eyes were hard for resident to keep open. R4's speech was more slurred than previous observation. On 5/9/2025 at 10:25AM, R4 was asked how she felt today and R4 stated, I am really tired. R4's Progress note dated 5/10/2025 at 1:09PM authored by V3 (LPN) documents, resident was getting out of her wheelchair when she lost her balance and fell landing on her right hip and right arm, V13 tried to catch her but couldn't. Resident then was sent to local hospital to be evaluated, family and V2, V1 (Administrator), and V20 were notified. An incident report sent to the Illinois Department of Public Health regarding R4 documents on 5/10/2025, at 1:09PM Resident observed on the floor by nurse's station. Resident was assessed immediately with noted pain to right hip. Resident's vitals were within normal limits. Medical doctor notified with orders to send resident to hospital for further evaluation and treatment. Power of Attorney notified. Emergency Medical Services arrived and transported resident to local hospital. Local hospital called the facility and notified staff that resident had suffered a right hip fracture. Medical doctor and Power of attorney. R4, 92, diagnosis Atrial Fibrillation, anxiety, Chronic Obstructive Pulmonary Disease, and age-related osteoporosis, BIMS 8. The resident ambulates about the facility independently. On 5/10/2025, around 1 PM, R4 was ambulating in A Hall and V13 was speaking with her and R4 stated her feet were tired and sore. There was an empty wheelchair sitting in the hall and V13 asked her if she would like to sit down and R4 said yes. After sitting in wheelchair, R4 said she wanted to speak with kids (they had just left the facility), so V13 asked R4 if she wanted to call them and R4 said yes. V13 pushed R4 up to the nurse's station to make the call. V13 went to retrieve a regular chair for R4 to sit in and R4 stood up, began to walk away. When V13 returned with the chair, R4 turned around, lost her balance, got her feet tangled together, and fell. At the time of the fall, R4 was wearing proper footwear, and the interventions were in place. After a thorough investigation that root cause of the incident is lack of balance and proprioception. Upon return from the hospital, a Medication Review will be completed by pharmacy consultant and results provided to the attending physician, hip protectors will be provided, and an order for physical therapy with a focus on balance and proprioception. The attending physician and power of attorney have been updated on the findings of investigation. R4's Emergency Department Provider Notes records dated 5/10/2025 at 2:47PM, documents Pt (patient) arrives via Ems (Emergency Medical Services) from (name of facility. Per EMS, pt got up from wheelchair, fell against a medcart, and fell to the ground on her R (right) side. Pt c/o (complains of) pain to R hip. R leg shortening and rotation noted. Under ED Course it documents Orthopedic surgery has been consulted; patient is to be admitted under the Trauma Service. Under Clinical Impression it documents Fall, initial encounter, Closed fracture of right hip, initial encounter. A hospital Procedure Note dated 5/12/25 documents Pre-operative Diagnosis: Right closed displaced intertrochanteric femur fracture and Procedure: Right short cephalomedullary nail. On 5/13/2025 at 1:00PM, V13 (Assistant Activity Director) called this surveyor over where V13 was standing in the dining room. V13 stated, Did you hear about (R4)? She fell and broke her hip, and I feel bad. V13 stated she was doing the one to one with R4 and R4 had been in a wheelchair all day. V13 stated R4's family member had left and R4 then wanted to call her family. V13 stated she pushed R4 up to the nurse's station but R4 wanted to call from her personal cell phone. V13 stated, I went down to (R4's) room to get her cell phone, I wish now I would have just pushed her down there with me, but I left her at the nurse's station while I ran down there really quick. V13 stated she got the phone and headed back up by the nurse's station and as she was approaching R4, R4 stood up and took a couple of steps and fell. V13 stated, I tried really hard to catch her, but I couldn't. V13 stated I feel so bad for leaving her. On 5/14/2025 at 9:53AM, V13 (Assistant Activity Director) stated actually R4 was out of it and more confused on Saturday. V13 stated R4 didn't try to get up much on Saturday to try to walk, but I would help her walk if needed. V13 stated on Saturday R4 was mostly in a wheelchair but I helped her to sit in a regular chair for meals and activities. V13 stated before the elopement (R4) moved pretty fast and on that day when she returned, I started the one on one and she was still the same, but then she became more sluggish with the medications. V13 stated she was working the day 5/8/2024 when the cop came in and talked R4 into taking a medication that R4 would not take for anyone else. V13 did not know what the medication was. V13 stated there was another girl at the nurse's station when R4 fell. V13 stated R4 was in pain after the fall, and she was trying to get up out of the floor. On 5/13/2025 at 3:10PM, V3 (LPN) came to the room this surveyor was working in and asked if she could talk for just a minute. V3 was tearful. V3 stated, I guess you know (R4) fell and broke her hip on Saturday (5/10/2025). V3 stated, I was working that day, and it was bad. V3 stated she knew that would happen and she even questioned the doctor about giving R4 the Xanax. V3 stated she told the doctor that R4 would end up falling. V3 stated you cannot give those drugs to residents that ambulate because it causes them to be unsteady. V3 stated, I know they were trying to keep her from eloping but now she is hurt. V3 stated she hated giving R4 those medications because of the effects of the medication. V3 stated you cannot give the elderly residents that much Xanax without causing bigger issues. V3 stated R4 stayed in a wheelchair all day up until she fell. On 5/14/2025 at 10:15AM, V3 stated she was R4's nurse on Saturday 5/10/2024. V3 stated, I did not see the fall as I had run to answer the front door alarm, and it was a family that did not know the code to get out. V3 stated R4 was sitting up against the wall by the Oxygen room near the nurse's station talking with another resident. V3 stated they were keeping R4 in a wheelchair for safety. V3 stated R4 has never had a fall before. V3 stated I had talked with the doctor with my concerns of the medications and contributing to possible falls, but he did not listen, ya know I am only a nurse. V3 stated, I know how those drugs effect the elderly's coordination and balance. V3 stated the Xanax did effect R4's coordination and unsteadiness on her feet. V3 stated the Xanax did make her a lot calmer as far as that goes. V3 stated she never gave R4 a Xanax when it was ordered just as needed. On 5/14/2025 at 9:35AM, V2 (DON) was asked what he knew about R4's fall. V2 stated he seen it on the video. V2 stated R4 was in a wheelchair across from the nurse's station. V2 stated V13 had gone to get a chair for R4 to sit in and when V13 came back around the corner she saw R4 stumble and fall. V2 stated R4 ambulates on her own anyway. V2 stated he told the nurses that if R4 started ambulating and going towards the door, to put her in a wheelchair. V2 stated nobody had reported to him that R4 had an unsteady gait. V2 stated when he left on Friday (5/9/2025), R4 was up ambulating all over the place. V2 was asked what diagnosis was used for the Risperidone medication and V2 stated Dementia with Psychosis. V2 stated since they didn't have a proper diagnosis (the diagnosis of Dementia with Psychosis), they didn't give but one dose. V2 stated Xanax was increased to three times a day. On 5/14/2025 at 10:45AM, V20 (Physician) stated the last time he saw R4 was before the elopement. V20 was asked why he started Xanax routinely on R4. V20 stated, Probably a suggestion to something to stop her from eloping and to make it easier to re-direct her. V20 was asked why he increased the dose of Xanax just 2 days later, V20 stated, I guess it was not doing any good. V20 stated, You normally give Xanax more time to evaluate the effects of the medication and dosage, 2 days is not really enough time to know that but they called and suggested the increase so I must have agreed. I depend on the nurses to assess the residents and make suggestions on what needs to be done. V20 was asked why he ordered Risperidone one time dose on 5/8/2025. V20 stated, I don't recall ordering that but they must have called and suggested and I agreed. V20 was asked why he would agree to the dose of 1mg. V20 stated, I can't imagine ordering that dosage for a patient of her size unless she was being very violent like trying to choke another resident or being aggressive uncontrollably. V20 stated, When I do use anti psychotics like that I always start at the dosage of 0.25mg never 1 mg. V20 stated there may have been miscommunication or he was busy and didn't hear the suggested dose and just agreed. V20 stated that dose was a dangerous dose for R4. V20 was asked what diagnosis he used to justify Risperidone and V20 stated, Dementia with Psychosis. At that time V20 was shown R4's diagnosis on the EMR (electronic medical record) which was Dementia without Psychosis. V20 stated, Well I believe she was showing signs of psychosis, she was hiding in a garage. V20 was asked if he was aware that on 5/7/2025 R4 was using a cane for ambulation. V20 stated, Yes, and I ordered an x-ray of her foot. V20 was asked if he was notified that R4 was then in a wheelchair on 5/8/2025, 5/9/2025 and 5/10/2025. V20 stated, No I was not aware of that. V20 was asked if he was aware that R4 was refusing the Risperidone from the staff and a cop friend of the family came to the facility and talked R4 into taking the medication? V20 stated, No I did not know anything about that either. V20 was asked if he felt like the Xanax could attribute to R4's fall with hip fracture. V20 stated, Yes, it is a high probability. V20 stated, That is why I don't usually use Benzo's (benzodiazepines) in geriatrics because it can affect their gait and other side effects that I don't like. V20 stated I used it this time as that is what they suggested due to anxiety, attempts to leave the facility and that is what the facility suggested. Physician orders were reviewed by EMR with V20 and V20 wanted to know who wrote all of the orders. Orders reviewed and orders were written by V2. V20 wanted to talk with V2 so V2 was summoned to the room at 11:02AM. V2 stated he had called for orders for medications to help with R4's continued exit seeking and anxiety. V20 checked his phone for calls received and validated the calls with the time the orders were placed and did not see any issues. V20 was asked if he was aware R4 was admitted (3/28/2025) with an as needed order for Xanax, V20 stated, I was never called to renew that order and that would have had to be done every 14 days, so I assume the order fell off. At that time R4's orders were reviewed with V20, and the as needed Xanax was discontinued on 5/6/2025. V20 stated, Again I don't like using Benzodiazepines in geriatrics because of the sedation effect. On 5/14/2025 at 12:14PM, a document titled Elopement incident report for R4 with documentation highlighted under subtitle of Notes was presented to this surveyor by V21 (Regional Clinical Director). The documentation highlighted was dated 5/8/2025, and authored by V19, documents 5/8/2025 Due to residents ongoing anxiety and wandering/exit seeking behavior the family requested (V20) be called and asked if there is anything to calm resident down. (V20) notified and initially gave a one time order for Risperidone then however he discontinued that and gave orders for Xanax 0.5mg 3x day. Family/POA and (V15) agreed with this. Resident being monitored for any adverse reaction or unwanted side effects such as gait changes, drowsiness, etc. On 5/9/2025, Resident continues the routine Xanax, and it does appear to be helping. Resident continues to be monitored for any adverse or unwanted side effects, and none are noted. Gait appears at baseline. Resident attended the Mother's Day Tea and interacted well with her family and had a good time. On 5/10/2025 authored by V3, Resident continues routine Xanax. Medication seems to be helping overall with resident's anxiety and behaviors. Resident continues to be monitored for any adverse or unwanted side effects and there have been one noted at this time. Gait appears to continue at her baseline. On 5/14/2025 at 12:18PM, V3 was asked if she assessed R4's gait on 5/10/2025. V3 stated. No, I had them to keep her in a wheelchair because I was worried about her. V3 was asked if she documented on the incident report that gait was at baseline, V3 stated, No and how would I be able to assess her gait if she was in a wheelchair. V3 was shown the document titled Elopement provided by V21 and the section under notes with documentation, on 5/10/2025 authored by V3. V3 reviewed the documentation and stated, I did not write that, someone has written that and put my name on it, and I did not do that. On 5/15/2025 at 12:49PM, V22 (Power of Attorney) and V15 (family member) were interviewed via telephone call and V15 stated R4 is doing better after surgery for hip fracture. V15 was asked if when she was there on 5/8/2025 did she know if R4 took the medication that they were trying to get R4 to take and V15 stated, Yes. V15 was asked if she knew what the medication was and V15 stated, Yes it was Risperdal. V15 stated (R4) kept talking about the police so my brother who was a fire chief called a friend who is a police officer to come and talk with R4. V15 stated, I guess (R4) trusted him because she took the medication for him. V15 was asked if she noticed any change in R4's mental status after the elopement. V15 stated on Thursday (5/8/25) she was sort of out of it and really sleepy. V15 stated she did ok through the Mother's Day event but yes, she had been more drowsy than normal. V15 asked if this surveyor knew exactly how R4 fell, V15 said the facility wasn't really sure. V15 stated she knew they still had one to one staff with R4 but thought that the staff member turned around and R4 stood up and just fell. V15 was asked if R4 was being sedated at the hospital and V15 stated no not really but she did have a sitter up until this morning. V15 stated, we are going back to the facility this evening so I think she will feel better there. R4's document titled Fall Risk Evaluation dated 5/10/2025 at 1:09PM, documents Category: At risk. Level of consciousness/mental state: Intermittent confusion, History of falls: 1-2 in last 3 months, Ambulation: ambulatory/continent. According to the FDA (Food and Drug Administration) website, https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020272s056,020588s044,021346s033,021444s03lbl.pdf., the drug label for Risperdal (Risperidone) documents Warning: mortality in elderly patients with Dementia-related Pdychosis . Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperdal is not approved for use in patients with dementia-related psychosis. According to the FDA website, https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/018276s052lbl.pdf. The drug label for Xanax documents Geriatric Use: The elderly may be more sensitive to the effects of benzodiazepines. They exhibit higher plasma alprazolam concentrations due to reduced clearance of the drug as compared with a younger population receiving the same doses. The smallest effective dose of XANAX should be used in the elderly to preclude the development of ataxia and oversedation. Dosing in Special Populations In elderly patients, in patients with advanced liver disease or in patients with debilitating disease, the usual starting dose is 0.25 mg, given two or three times daily. This may be gradually increased if needed and tolerated. The elderly may be especially sensitive to the effects of benzodiazepines. If side effects occur at the recommended starting dose, the dose may be lowered. The facility Psychotropic Medication Use policy with revision date of December 2016 documents, Policy statement: Psychotropic medications may be considered for residents after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Psychotropic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. 1. Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The Attending and Physician and other staff will gather and document information to clarify a resident's behavior, mood, medical condition, specific symptoms, and risk to residents and others. On 5/16/25, Behavior Tracking for R4 was requested. R4's Behavior Tracking documents a start date of 5/14/25 for behaviors of restlessness, makes repetitive statements about wanting to go home, resident gets agitated at times with staff, and wandering. There was no other behavior tracking provided prior to the date of 5/14/25.