Based on interview and record review, the facility failed to prevent a significant medication error, resulting in the hospitalization of a resident for altered mental status. (Resident B) Findings include: Resident B's closed clinical record was reviewed on 7/2/25 at 11:08 a.m. Diagnoses included displaced fracture of right femur, atrial fibrillation (irregular heartbeat), heart disease. The resident admitted to the facility from the hospital on 6/27/25. Current physician orders include buprenorphine-naloxone (treats narcotic dependence) 8-2 milligram (mg) sublingual twice a day, tramadol (opiate pain medication) 50 mg every six hours, ciprofloxacin (antibiotic) 500 mg one tablet twice a day for three days for urinary tract infection (UTI), iron 325 mg one tablet daily for anemia, and potassium gluconate 595 mg daily for hypokalemia. A current care plan, dated 6/27/25, indicated Resident B was at risk for atrial fibrillation. Interventions included administering medication as ordered, aspirin as ordered, Eliquis as ordered, monitor vital signs as needed, notify physician if any concerns, and obtain her pulse as indicated. A current care plan, dated 6/27/25, indicated Resident B had a recent history of a fracture and was at risk for pain and infection due to right femur fracture. Interventions included assess pain location, duration, intensity, and frequency, assess the residents level of pain as needed, monitor of signs and symptoms of infection/complications such as: elevated temperature, redness, swelling, and or warmth. Notify the nurse of any problems for further evaluation and possible physician and resident representative notification, offer pain medication as ordered and monitor effectiveness. Review of a pharmacy consolidated delivery sheet dated 6/27/25 indicated naloxone (Narcan) hcl 4 mg nasal spray was administered and checked off as being received by LPN 8 on 6/27/25. On 6/28/25 at 10:58 a.m., Resident B was alert and oriented. Resident B's speech was clear and she was able to make her needs known. Resident B's pulse was strong and regular. Resident B denied any chest pain, feeling of her heart racing, or being fatigued. Resident B complained of right hip pain that was relieved with prescribed medications. A June 2025 Medication Administration Report (MAR) indicated buprenorphine-naloxone 8-2 mg was administered by LPN 4 on 6/27/25 between 6:30 p.m. and 10:30 p.m. A progress note, dated 6/28/25 at 9:01 p.m., indicated Resident B had complaints of being hot and yawning. Resident B's blood pressure was 180/100 millimeters of mercury (mmHg). Staff were unable to obtain her oxygen saturation. A new order was received to send Resident B to the hospital for evaluation and treatment. A call was placed to 911. Emergency Medical Technicians (EMTs) arrived and transported Resident B to the hospital. Hospital Records, dated 6/28/25 and 6/29/25, indicated Resident B admitted with complaints of altered mental status after receiving 4 mg of intranasal Narcan. Resident B had a history of atrial fibrillation (abnormal heart rhythm) and had been off her Eliquis (blood thinner) due to an upcoming surgery. Resident B was cardioverted (shocked) back into normal sinus rhythm after the third attempt. Resident B continued to be agitated after the cardioversion, but her blood pressure had initially been stable afterward. A hospital physician note indicated Resident B was in shock with a blood pressure of 79/31 mmhg. Resident B was admitted to the ICU due to cardiogenic shock (heart cannot pump well) with acute cystitis (kidney infection) without hematuria with shock. During an interview, on 7/2/25 at 12:06 p.m., the facility's Pharmacist indicated naloxone (Narcan) nasal spray was sent to the nursing facility. If naloxone was administered, a residents blood pressure would need to be monitored. Side effects from the naloxone include sweating or flushing, hot flashes, abdominal cramping, vomiting, disorientation or dizziness. Side effects could also affect the heart rate. When someone is in pain, symptoms include body sweats and increased heart rate. The resident's symptoms could have been from pain, withdrawal, or the medication. On 7/2/25 at 12:54 p.m., LPN 4 indicated Resident B was playing cards at the time of the medication administration. The naloxone nasal spray was in the bottom of the medication cart. Resident B received tramadol then administered the naloxone instead of the ordered buprenorphine- naloxone. LPN 4 helped Resident B administer the naloxone nasal spray. The nurse indicated she normally checked the label against the medication. She had noticed the buprenorphine- naloxone was ordered as a film and the naloxone was a nasal spray, but was unable to recall when she noticed that. Roughly 10 minutes later, another nurse advised LPN 4 to assess Resident B, as she was experiencing symptoms. Resident B was displaying trembling, complaint of being hot. She was oriented and able to state she was shaking and trembling. Her blood pressure was low. On 7/2/25 at 1:30 p.m., the facility's Medical Director indicated Resident B was discharged from the hospital on 6/27/25 following hip surgery with an order for buprenorphine- naloxone, but the hospital did not send in a prescription to the pharmacy. If buprenorphine- naloxone was stopped abruptly, one would start experiencing withdrawal symptoms. Withdrawal symptoms would not happen several hours after her hospital discharge. Naloxone's effect would not be long lasting in a person's system, which is why the medication can be administered every few minutes. The two most common causes of cardiogenic shock were heart attack or sepsis. A person's age, along with other commodities including anemia, which Resident B could have experienced due to her surgery, would affect her heart. Within the first 90 days following hip surgery, those resident become very bedridden, not wanting to move around. Age, anemia, and dehydration increased the risk of developing deep vein thrombosis (DVT) or pulmonary embolism (PE). From his medical standpoint, he felt Resident B likely suffered from sepsis, heart attack, or maybe even a PE. Any of these three conditions could put someone into cardiogenic shock. On 7/2/25 at 3:09 p.m., RN 7 indicated the Nurse Practitioner (NP) discontinued the naloxone order upon the resident's admission to the facility. RN 6 was unaware the naloxone was ordered through the pharmacy. The naloxone was never ordered through the facility. It only existed on Resident B's hospital discharge medication summary. On 7/2/25 at 3:34 p.m., LPN 8 indicated she did not recall receiving naloxone from the pharmacy. She placed medication in the resident's drawer; any medication overflow would be placed in the bottom drawer of the mediation cart. A current facility policy, dated 4/2017, titled Medication Administration, provided by the Administrator, on 7/3/25 at 3:37 p.m., indicate the following: Guidelines for medication administration: 1. Medications are administered to residents only as prescribed and only by person licensed or qualified to do so. 10. Always observe the six rights of giving each medication: right resident, right medicine, right time, right dose, right route, right documentation. 11. Read the label and MAR three times when preparing the medication This citation relates to Complaints IN00462642 and IN00462522. 3.1-25(b)(9)

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience for 1 of 14 residents observed during dining on the secured unit. (Resident 35) Finding includes: During an observation, on 8/26/24 at 12:32 p.m., Resident 35 sat in her wheelchair at the dining table. Her chair was low in comparison to the table height and put the resident at chin level to the table. She took a bowl of food off her tray on the table and put the bowl in her lap to eat. During an observation, on 8/27/24 at 12:17 p.m., CNA 6 assisted the resident in her wheelchair to the dining table. The resident's chin was at the level of the table and close to the table edge. She reached up to the tray on the table to get some potato chips. During an observation, on 8/28/24 at 12:14 p.m., the resident sat at the dining table. Her chin was at table height. She reached up to get a food bowl from her tray and held it while eating. Resident 35's clinical record was reviewed on 8/26/24 at 3:54 p.m. Her diagnoses included Alzheimer's disease with late onset, dementia, visual hallucinations, depression, anxiety disorder, and abnormal weight loss. The current physician's orders included mirtazapine (for appetite stimulant) 7.5 mg daily at bedtime (started 5/7/24) and resident is to have all foods served in bowls at every meal (started 3/13/24). A significant change Minimum Data Set (MDS) assessment, completed on 6/28/24, indicated the resident was moderately cognitively impaired. She required supervision to touching assistance with eating and partial to moderate assistance with transfers. She had experienced a significant weight loss. A care plan for eating, initiated on 3/20/24 and last revised on 7/2/24, indicated the resident required staff assistance for meal consumption. The interventions included ensure resident is seated in an environment which will provide staff assistance and encourage meal consumption. During an interview, on 8/29/24 at 4:01 p.m., the DON indicated she was aware the resident sat a little low in her chair to the table. She thought they had tried a bedside table for dining but was uncertain if any other interventions had been attempted. During an interview, on 8/30/24 at 8:46 a.m., CNA 7 indicated the resident almost always sat at the regular dining table until today. A lower table had been brought into the dining room for her. The resident may have used a bedside table as her dining table at some time, but CNA 7 did not remember much about it. During an interview, on 8/30/24 at 8:47 a.m., LPN 5 indicated the resident had an order for her food to be placed in bowls so she could put in her lap because she sat low at the table. She had placed her plate in her lap prior to getting the bowls which made it difficult for her to eat. They had briefly tried to have her sit in a regular chair, but she stood up as soon as she was done with her meal and tried to leave. She was a fall risk, so the wheelchair was used to prevent falls. During an interview, on 8/30/24 at 11:16 a.m., the DON indicated she had spoken to the Administrator about the resident's seat height to the table height. They had not thought about it being an issue. During an interview, on 8/30/24 at 11:24 a.m., the Administrator indicated the facility did not have a policy on dining. 3.1-3(t) 3.1-3(v)(1)

Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a new mental health diagnosis. (Resident 12) Finding includes: Resident 12's clinical record was reviewed on 8/27/24 at 1:49 p.m. Diagnoses included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (1/20/23), schizophrenia (1/20/23), major depressive disorder (1/20/23), generalized anxiety disorder (4/28/23), psychotic disorder with delusions due to known physiological condition (5/31/23), and restlessness and agitation (5/31/23). Physician's orders included buspirone (antianxiety) 10 mg twice a day (started 8/13/24), lamotrigine (for schizophrenia) 25 mg twice a day (started 8/18/23), and olanzapine (antipsychotic) 15 mg twice a day (started 8/13/24). A care plan for physical behavior symptoms directed towards others, initiated on 5/11/23 and last revised on 8/8/24, indicated the resident exhibited physical behavioral symptoms directed towards others such as hitting and throwing things. Interventions included psychoactive medications as ordered which included lamotrigine and olanzapine. A care plan for delusions, initiated on 4/25/23 and last revised on 8/8/24, indicated the resident suffered from delusions due to schizophrenia as he believed there was a horse in his room that was trying to hurt him and his roommate, believed people are going to cut off his toes, and thought staff was out to get him. Interventions included notify nurse and social services for further evaluation and possible physician and resident representative notification and administer medications as ordered which included lamotrigine and olanzapine. A mood and behavior communication memo, dated 5/6/24 no time, indicated the resident thought people were out to get him and kill him. He thought someone was going to shoot him and isolated in his room due to those beliefs. A mood and behavior communication memo, dated 5/15/24 at 3:00 p.m., indicated the resident said the dietary personnel had poisoned his dinner the night before. A mood and behavior communication memo, dated 6/20/24 at lunch time, indicated the resident refused to come out of his room from lunch. He said someone one would kill him if he came out of his room with his work shirt on. A PASRR completed on 7/1/23 did not indicate the resident's current mental health diagnoses. During an interview, on 8/28/24 at 4:00 p.m., the DON indicated she would look for the most recent PASRR completed for the resident, including the application. Review of the PASRR Level 1 Screen Outcome, dated 8/29/24, provided by the Social Services Director on 8/29/24 at 10:38 a.m., indicated the Level 1 had been submitted on 8/28/24. The PASRR Level I Determination indicated a Level II evaluation must be conducted. During an interview, on 8/29/24 at 2:02 p.m., the Corporate Social Services Consultant indicated the facility did not have a policy for PASRR Level l. They followed the PASARR provider guidelines. During an interview, on 8/29/24 at 3:04 p.m., the Social Services Director indicated a new Level I had been submitted on 8/28/24 for the resident because she had noticed he had new psychological diagnoses that required an updated Level l. Review of the Indiana PASRR FAQs for providers [frequently asked questions], revised 2022, accessed on 9/3/24 at 9:48 a.m. at maximusclincalservices.com, indicated the following: .If a significant change in mental health status has occurred since the last approval, a new Level I screening is required When is Status Change review required? Whenever there is a change in the mental status of an individual, since the prior Level 1 review

Based on interview and record review, the facility failed to monitor vital signs per physician orders prior to giving medications for 3 of 3 residents reviewed. (Resident 24, 31, and 35) Findings include: 1. Resident 24's clinical record was reviewed on 8/27/24 at 9:45 a.m. Diagnoses included dementia, old myocardial infarction (heart attack), unspecified atrial fibrillation (rapid and irregular heart rate), and hypertension (high blood pressure). Resident orders included metoprolol tartrate (high blood pressure) 25 milligram (mg) tablet twice daily, hold if heart rate is below 60 and/or systolic blood pressure (top number) is below 120. A Consultant Pharmacist's Medication Regimen Review for May 2024, provided by the DON on 8/28/24 at 2:09 p.m., indicated the Medication Administration Report (MAR) showed that in the last couple of weeks, this dose was administered eight times when the residents systolic blood pressure was less than 120. Please make sure to hold when indicated. A Medication Administration Report (MAR), for June 2024, indicated the resident received metoprolol tartrate as follows: On June 4th a.m., with a systolic blood pressure of 80. On June 4th p.m., with a systolic blood pressure of 119. On June 7th p.m., with a systolic blood pressure of 104. On June 9th p.m., with a systolic blood pressure of 107. On June 13th a.m., with a systolic blood pressure of 87. On June 14th p.m., with a systolic blood pressure of 107. On June 15th a.m., with a systolic blood pressure of 106. On June 16th a.m., with a systolic blood pressure of 115. On June 19th a.m., with a systolic blood pressure of 114. On June 27th a.m., with a systolic blood pressure of 118. On June 29th a.m., with a systolic blood pressure of 104. On June 29th p.m., with a systolic blood pressure of 110. On June 30th a.m., with a systolic blood pressure of 100. A Medication Administration Report (MAR), for August 2024, indicated the resident received metoprolol tartrate as follows: On August 7th p.m., with a systolic blood pressure of 116. On August 11th p.m., with a systolic blood pressure of 113. On August 12th a.m., with a systolic blood pressure of 113. On August 13th a.m., with a systolic blood pressure of 112. On August 13th a.m., with a systolic blood pressure of 105. On August 16th p.m., with a systolic blood pressure of 118. On August 24th p.m., with a systolic blood pressure of 116. On August 25th a.m., with a systolic blood pressure of 93. Resident 24's comprehensive care plan, revised on 7/24/24, indicated she had a diagnosis of hypertension and is at risk for associated complication. Interventions included administering medications as ordered, monitor blood pressure routinely and notify physician and resident representative per call order parameters, metoprolol per doctor order, monitor blood pressure and heart rate per order. 2. Resident 31's clinical record was reviewed on 8/27/24 at 11:08 a.m. Diagnoses included essential (primary) hypertension, unsteadiness on feet, unspecified atrial fibrillation (rapid and irregular heart rate), and unspecified tachycardia (rapid heartbeat). Resident orders included metoprolol tartrate (high blood pressure) 25 mg tablet twice daily, hold if heart rate is below 70. Cozaar (high blood pressure) 25 mg tablet once daily, hold for systolic blood pressure below 120. A Medication Administration Report (MAR), for June 2024, indicated the resident received losartan as follows: On June 1st, with a systolic blood pressure of 114. On June 22nd, with a systolic blood pressure of 118. A Medication Administration Report (MAR), for July 2024, indicated the resident received losartan as follows: On July 9th, with a systolic blood pressure of 115. On July 21st, with a systolic blood pressure of 118. On July 21st, with a systolic blood pressure of 118. A Medication Administration Report (MAR), for August 2024, indicated the resident received losartan as follows: On August 14th, with a systolic blood pressure of 119. On August 22nd, with a systolic blood pressure of 107. Resident 31's comprehensive care plan, revised on 7/30/24, indicated he had a diagnosis of hypertension and is at risk for associated complication. Interventions included administering medications as ordered, monitor blood pressure routinely and notify physician and resident representative per call order parameters, administer losartan, and check blood pressure and heart rate. 3. Resident 35's clinical record was reviewed on 8/26/24 at 3:54 p.m. Diagnoses included dementia, heart failure, edema, essential (primary) hypertension, repeated falls, and multiple rib fractures. Resident orders included metoprolol succinate (high blood pressure) extended release 75 mg tablet once daily, hold if heart rate is below 60. A Medication Administration Report (MAR), for July 2024, indicated the resident received metoprolol succinate daily July 23rd through July 31st even though her heart rate was not recorded on the MAR. A Medication Administration Report (MAR), for August 2024, indicated the resident received metoprolol succinate daily August 7th through August 14th even though her heart rate was not recorded on the MAR. No vitals were recorded under vital signs from July 23rd through August 8th. Resident 35's comprehensive care plan, revised on 7/23/24, indicated she had a diagnosis of hypertension and is at risk for associated complication. Interventions included administering medications as ordered, monitor blood pressure routinely and notify physician and resident representative per call order parameters. During an interview, on 8/29/24 at 12:02 p.m., LPN 5 indicated for the medications that are ordered with parameters, the computer requires the user to put in those parameters before being able to proceed to administer the medication. If a number is put in outside of the parameter, it will notify the user that it is out of range. The user would need to hit the okay button or cancel the administration altogether. When the user hits the cancel button, then she can put in that the medication was not administered due to condition. When the users clicks on the medication she wants to give it will pop up a box for vital signs if those are needed before administering the medication. Once those have been entered, the user would then click prep. You would then hit complete to indicate the medication was administered. It would be very difficult to accidentally administer the medication when the user has three steps to go through to finalize that the medication was given. On medications that require a blood pressure or heart rate, there is a red star where you must enter the vitals before it lets you proceed to the next step. During an interview, on 8/28/24 at 12:18 p.m., LPN 8 indicated the physician put parameters on certain medications like blood pressure or heart rate. The medication would be held if the vitals were not within the parameter range. She would click that the medication was not given and give a reason why it was held. During an interview, on 8/28/24 at 12:19 p.m., LPN 9 indicated she takes vitals on medications with parameters. If the vitals are not within the parameter range, she would hold the medication and indicate why the medication was not given. During an interview, on 8/29/24 at 3:36 p.m., the DON indicated an in-service on parameters was just completed for the nurses and the Qualified Medication Aides (QMA). They all verbalized they understood and will check vitals prior to administering medications. If they don't give a mediation, they will document a reason why it wasn't given. A current facility policy, revised 4/2017, titled Medication Administration, provided by the DON, on 8/29/24 at 2:04 p.m., indicated the following: .Purpose: To safely administer medications as per physicians' orders. 20. Always take pulse and B/P as indicated if ordered prior to giving certain cardiac or antihypertensive drugs 3.1-37(a)

Based on observation, record review, and interview, the facility failed to develop and implement individualized interventions to reduce physical aggression toward a resident (Resident 29) by a resident with dementia (Resident 23). Findings include: During an observation, on 9/29/23 at 8:50 a.m., Resident 23 was sitting in a wheelchair in the lounge with six other residents. Her clinical record was reviewed on 9/29/23 at 2:06 p.m. Diagnoses included, dementia, unspecified severity, with agitation, anxiety, depression, and psychotic disorder with delusions due to known physiological condition. Current physician orders included Rexulti (anti-psychotic), 1 mg (milligram) tablet once a day, with an order date of 6/21/23, Remeron (antidepressant), 15 mg tablet once a day at bedtime, with an order date of 8/22/23, and Zoloft (antidepressant), 100 mg tablet, take one and one-half tablets to equal 150 mg once a day, with an order date of 8/22/23. A 7/15/23 quarterly MDS (Minimum Data Set) assessment indicated she had severe cognitive impairment. She required supervision with bed mobility and transfers, and was independent with locomotion on and off the unit A current mental health service care plan, dated 11/20/20 with last revision date of 9/6/23, indicated she received mental health services due to depression, anxiety, delusions, hallucinations, and psychotic disorder with delusions. The goal indicated she would accept mental health services as ordered through next review. Interventions included, mental health services provided as ordered, continue to observe for significant change in mood/behavior such as crying, negative statements, isolation, change in daily routine, changes in eating or sleeping habits, etc., and notify physician and resident representative upon any significant change. A current physical behavioral symptoms directed towards others care plan, dated 8/14/22 with last revision date of 9/6/23, indicated she exhibited physical behavioral symptoms directed towards others such as hitting, kicking, pushing, and grabbing due to dementia with delusions. The goals indicated her behavior would not have a significant impact on self or others daily and interventions would be effective as evidenced by fewer episodes through next review. Interventions included, upon any signs and/or symptoms of agitation, don't begin care, if care had started and she became combative, stop care, ensure safety, and allow her to calm down, allow the resident time to calm and then re-approach, try to identify the immediate cause for the behavior, and limit distractions. A progress note, dated 6/9/23 at 7:49 p.m., indicated Resident 23 had been violent with staff and another resident, and had been difficult to redirect. She was taken to a nearby hospital by her family. A progress note, dated 6/10/23 at 1:37 a.m., indicated the hospital had noted her heart rate to be elevated in the 120s, had received intravenous medication, and was monitored. The resident was expected to return to the facility when her heart rate was stabilized. A progress note, dated 6/10/23 at 3:19 a.m., indicated a nurse from the hospital had called the facility to report the resident had become agitated when she had been told she would be returned to the facility. She hit and spat on staff and attempted to exit seek. The hospital delayed discharging her back to the facility and planned to have a psychological evaluation completed. A progress note, dated 6/21/23 at 2:43 p.m., indicated she had returned to the facility from a behavioral unit. A Mood and Behavior Communication Memo, dated 6/22/23 at 11:30 p.m., indicated she had the following behaviors: made negative statements, verbally and physically aggressive, socially inappropriate, and had delusions. She had been going into other resident's rooms going through their things, slamming doors, and fighting when she had been told she needed to leave the room. The interventions attempted included one on one provided with her, conversation of interest, and redirection. All were unsuccessful. A Mood and Behavior Communication Memo, dated 7/5/23 at 4:30 p.m., indicated she had the following behaviors: made negative statements, agitation, restlessness, and had been physically aggressive. She had grabbed a nurse's wrist and tried to twist it, and hit the nurse with a closed fist. The interventions attempted included one on one provided with her, conversation of interest, and redirection. All indicated they had all been unsuccessful. A progress note, dated 7/5/23 at 9:32 p.m., indicated she had tried to get out of the secure unit multiple times, argued and threatened to get physical with other residents, and hit a staff member. A Psychiatry NP (Nurse Practitioner) Progress Note, dated 7/13/23, indicated her delusional disorder was stable. Rexulti 1 mg daily was continued. Her dementia was severe, and appropriate behavioral interventions and psychotherapeutic communication were continued. A Mood and Behavior Communication Memo, dated 9/6/23 at 5:00 p.m., indicated she had the following behaviors: made negative statements, agitation, and physically and verbally aggressive. Staff assisted her with donning a clothing protector and she hit them in the face. The interventions attempted included toileting, changed position, provided fluids, provided relaxation techniques, walked with her, massage hand, shoulders and back, provided quiet environment, placed in chair and/or bed, provided an object to hold/manipulate, engaged in physical activity, provided snack, provided one on one with her, allowed her to vent her feelings, conversation of interest, activity of choice and interest, provided reassurance and comfort, called family for assistance, used humor, television and/or radio, provided pleasant pictures or photo album, time to calm/re-approach, redirection, as needed medication administered, managed pain, called physician, mental health services, hospitalized , repetitive activities of folding, sorting, stacking and rocking, validation of feelings and words, and report of concern completed. All interventions had been unsuccessful. A progress note, dated 9/19/23 at 11:35 p.m., indicated around 7:30 p.m., she had gotten angry because she had seen another resident with a stuffed dog, and yelled there were not supposed to dogs/animals here. She made her way towards resident's room while a CNA assisted him to bed. She was heard yelling and had become more angry, nurse attempted to talk with her, and the resident hit her twice when she attempted to remove her via the wheelchair from the other room. Ten minutes later, as the CNA assisted another resident for bed, Resident 23 approached them in her wheelchair. She was mean and yelling, and the nurse looked down the hall and saw the resident grab the other resident's right arm (Resident 29). The nurse ran to help the CNA, and the resident tried to bite and hit the nurse. The CNA got the other resident in the room and closed the door. The nurse tried to talk with her, but she was agitated and mean, and was following residents up and down the hall. Resident 23's family was notified and they took the resident to a nearby hospital. A progress note, dated 9/20/23 at 12:15 a.m., indicated she had returned to facility from the emergency room. No new orders had been received. During an interview, on 10/2/23 at 8:47 a.m., CNA 7 indicated Resident 23 got agitated easily, and had entered other resident's rooms and tried taking things from them. During an interview, on 10/2/23 at 8:49 a.m., CNA 5 indicated the resident was not always easily redirected when she had behaviors. During an interview, on 10/3/23 at 9:58 a.m., the Nurse Consultant indicated the resident had been to a behavioral unit a couple of times recently. During an observation, on 10/3/23 at 1:40 p.m., Resident 29 was lying in bed. Her clinical record was reviewed on 10/3/23 at 1:41 p.m. Diagnoses included age-related physical debility, dementia without behavioral disturbance, anxiety, and depression. Current physician orders included Zoloft 50 mg tablet, give with 100 mg tablet to equal 150 mg, daily for depression. A 7/15/23 significant change MDS assessment indicated she had severe cognitive impairment. She required supervision to transfer, walk in room, and with locomotion on the unit. She required limited assistance to walk in corridor and with locomotion off the unit. A current secure unit care plan, dated 10/15/21 with last revision date of 9/13/23, indicated she required placement on a secured unit due to Alzheimer's. The goal indicated she would continue to reside on the secured unit providing therapeutic environment as evidenced by the resident not wandering from the facility through next review. Interventions included, resident allowed to move about freely in the secured unit as long as the resident's safety is ensured. Her clinical record did not include information about her right arm having been grabbed by another resident, or any follow up related to possible psych-social harm resulting from the incident. During an interview, on 10/3/23 at 10:00 a.m., the Administrator indicated Resident 23 had not been involved in any resident to resident altercations. He considered any willful contact from one resident to another resident to be abuse, and since no residents had been harmed in any of the events, he didn't feel he needed to report them. Regarding the incident on 6/9/23, Resident 23 had been sent to the hospital because she had been difficult to re-direct and had normally been easy to re-direct. Regarding the incident on 7/5/23, the facility investigation determined there was no immediate threat and she had been easily re-directed. The investigation into the incident on 9/19/23 determined Resident 23 was trying to protect Resident 29. Review of 2023 online Alzheimer's Association education titled Treatments for Behavior, retrieved from https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior, indicated the following: .Non-drug approaches .Non-drug approaches to managing behavior symptoms promote physical and emotional comfort. Many of these strategies aim to identify and address needs that the person with Alzheimer's may have difficulty expressing as the disease progresses. Non-drug approaches should always be tried first. Steps to developing successful non-drug treatments include: Recognizing that the person is not just acting mean or ornery, but is having further symptoms of the disease. Identifying the cause and how the symptom may relate to the experience of the person with Alzheimer's 3.1-37(a)

Based on observation, record review, and interview, the facility failed to ensure medication was secured after medication administration for 1 of 4 residents observed during medication administration (Resident 11). Finding includes: During an observation, on 10/3/23 at 9:55 a.m., Resident 11 was given his medications crushed in pudding, followed by sips of nectar thick liquid containing polyethylene glycol (laxative). The resident became fatigued while swallowing his medications and LPN 51 placed the cup of the remaining liquid containing the polyethylene glycol on the resident's bedside table, left the room, and pushed the medication cart down the hallway. During an interview, at the time of the observation, LPN 51 indicated she was leaving the cup containing the liquid and polyethylene glycol for the CNAs (certified nurse aides) to help the resident to drink later. During an interview, on 10/3/23 at 1:50 p.m., the DON indicated LPN 51 should have taken the cup of liquid with medication with her when she left the room. A current facility policy, revised 4/2017, titled Medication Administration, provided by the Corporate Clinical Nurse on 10/3/23 at 2:04 p.m., indicated the following: .Always observe the resident taking their medication(s). Never permit medication to remain in the resident's room. 3.1-25(m)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure 1 of 7 residents reviewed for immunizations received a pneumococcal vaccination to remain up to date with pneumococcal vaccination (Resident 24). Finding includes: Resident 24's clinical record was reviewed on 9/29/23 at 3:40 p.m. His diagnoses included chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease of the coronary artery, and chronic kidney disease. An Informed Consent for Pneumococcal Vaccine form was signed by the resident's legal representative on 1/25/22. An Immunization/Mantoux Record, provided by the Administrator on 10/2/23 at 3:44 p.m., indicated the resident had received the pneumococcal 13-valent conjugate vaccine on 3/25/22. The form lacked documentation of a refusal or a medical contraindication for an additional pneumococcal vaccination. During an interview, on 10/2/23 at 4:08 p.m., the Administrator indicated the immunization records had been removed from the paper charts. Medical records staff had been entering the information in the electronic charts. The facility was having difficulty retrieving some of the information that had been entered into the electronic record. During an interview, on 10/3/23 at 9:40 a.m., the Administrator indicated he tracked the COVID-19 immunizations, and the DON tracked the other immunizations. During an interview, on 10/3/23 at 2:00 p.m., the DON indicated she utilized a spreadsheet to track the residents' immunizations. Resident 24 had received one pneumococcal vaccination and was due for another one. The facility had administered several pneumococcal 20-valent conjugate vaccines this past July. She was uncertain if Resident 24 had received the vaccine at that time. During an interview, on 10/3/23 at 2:25 p.m., the DON indicated the resident had been missed when the facility administered the pneumococcal 20-valent conjugate vaccines to the residents in July. An online reference titled Pneumococcal Vaccine Timing for Adults (3/15/23), retrieved on 10/3/23 from the Centers of Disease Control (CDC) website, indicated for adults [AGE] years old and older - if the pneumococcal 13-valent was the only prior pneumococcal vaccine received, then the pneumococcal 20-valent conjugate vaccine or the pneumococcal polysaccharide vaccine should be received at one year or greater after the prior vaccine to be up to date with pneumococcal vaccination. A current facility policy, dated 10/2015, provided by the Administrator on 9/27/23 at 11:00 a.m. during the facility entrance conference, titled Pneumococcal Disease Immunization, indicated .offer and vaccinate all residents against pneumococcal disease according to the guidelines set forth by state and federal regulations, unless medically contraindicated .If the vaccine is medically contraindicated or refused, this information must appear on the Immunization Record 3.1-13(a)

Based on observation, interview and record review, the facility failed to ensure residents had access to call lights for 3 of 3 residents reviewed for accommodation of needs (Residents 189, 2 and 35). Findings include: 1. During and observation, on 8/9/22 at 8:39 a.m., Resident 139 was lying in a low bed, the call light was under the low bed. On 8/9/22 at 1:39 p.m., she was lying in bed against the assist rail, the call light was in the waste-basket and not within her reach. The resident's clinical record was reviewed on 8/9/22 at 10:36 a.m. Diagnoses included, but were not limited to, debility. A 7/19/22 admission MDS (Minimum Data Set) assessment indicated she had moderate cognitive impairment and was totally dependent with bed mobility and toilet use. During an interview, on 8/10/22 at 8:48 a.m., LPN 7 indicated the resident was able to use the call light to ask for assistance. 2. During an interview, on 8/8/22 at 1:37 p.m., Resident 2 was in his room in his wheelchair. He indicated he was waiting for his therapy session. His call light was secured to the bed behind him, out of his reach. He indicated he would have called to see when the therapist was coming, but he could not reach the call light. He couldn't transfer himself or propel the wheelchair due to weakness. On 8/8/22 at 1:42 p.m., COTA 34 entered the room and assisted the resident to the therapy room. Review of Resident 2's clinical record was completed on 8/8/22 at 2:10 p.m. A 4/15/22, quarterly, Minimum Data Set (MDS) assessment indicated he was cognitively intact and was dependent for transfers and locomotion. 3. During a care observation, on 8/10/22 at 11:03 a.m., Resident 35 was in bed. His call light was secured to the right side of his bed, while the resident was propped with pillows on his left side. During an interview, at the time of the observation, RN 35 indicated the resident was capable of using his call light, and it should have been kept in reach. Resident 35's clinical record was reviewed on 8/9/22 at 11:25 a.m. A 7/4/22, quarterly, MDS assessment indicated he was moderately cognitively impaired and required extensive assistance with bed mobility. Review of a current facility policy titled CALL LIGHT, dated 10/2014 and provided by the Administrator on 8/12/22 at 8:45 a.m., indicated the following: .Resident will have a call light to summon facility personnel to ensure the resident's needs will be met .Resident's call light is to be within reach 3.1-3(v)(1)

Based on record review and interview, the facility failed to ensure a resident's advance directive was reviewed and signed by the resident or representative for 1 of 16 reviewed for advance directives in the initial pool (Resident 23). Findings include: Resident 23's clinical record was reviewed on 8/8/22 at 10:27 a.m. Diagnoses included, but were not limited to, major depressive disorder, recurrent severe without psychotic features,, dementia with behaviors, psychosis, and Alzheimer's disease. He had a current, signed physician's order for do not resuscitate. During an interview, on 8/12/22 at 9:29 a.m., the admission Coordinator indicated Advance Directives were kept in the resident charts. During an interview, on 8/12/22 at 1:30 p.m., the Administrator indicated the resident's representative had filled out the information on the form for 1st and 2nd choice contacts, but had apparently forgotten to sign the form. Review of a current facility policy titled Advance Directive, dated 1/2015 and provided by the Administrator on 8/12/22 at 1:05 p.m. indicated the following: .When presented with an Advance Directive document, the facility shall verify the attending physician has a copy of the document and shall place a copy .as well as on the resident's clinical record in the nurses station 3.1-4(l)(4)(A)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately screen for mental disorders prior to admission for 1 of 7 residents reviewed for Preadmission Screening and Resident Review (PASARR). (Resident 40) Findings include: Resident 40's clinical record was reviewed on 8/11/22 at 11:06 a.m. Physician's admission orders for 6/1/22 included, but were not limited to, quetiapine (antipsychotic) 50 mg daily at bedtime and melatonin (hormone that regulates the sleep cycle) 6 mg daily at bedtime. A social history and psychosocial assessment dated [DATE] lacked documentation of the physician's order for quetiapine. The current psychoactive medication section was blank. Progress notes dated 6/2/2022 from the Nurse Practitioner (NP) indicated quetiapine 50 mg daily was ordered. A social service assessment dated [DATE] lacked documentation of the quetiapine order. The PASARR with a review date of 6/3/22 listed a medication order for lorazepam (antianxiety) oral liquid 0.5 mg as discontinued under the mental health medications and lacked an entry for quetiapine. An interdisciplinary care plan conference record dated 6/6/22 listed melatonin under psychoactive medications and lacked documentation of the quetiapine order. During an interview, on 8/11/22 at 2:11 p.m., the Social Services Director indicated she vaguely remembered Resident 40. She indicated she did not remember the resident's quetiapine order. The PASARR lacked documentation of the physician's quetiapine order. During an interview, on 8/12/22 at 10:38 a.m., the Nurse Consultant indicated the facility did not have a facility PASARR policy and used the state guidelines. 3.1-16(d)

Based on observation, record review and interview, the facility failed to identify and implement individualized, non-pharmacological interventions for residents with expressions of behavior for 3 of 4 residents reviewed for dementia care (Residents 31, 33 and 5). Findings include: 1. During an observation, on 8/9/22 at 1:56 p.m., Resident 31 was lying in bed. On 8/10/22 at 9:51 a.m., she was lying in bed. On 8/11/22 at 8:58 a.m., she was sitting in a wheel-chair in the dining room. Her clinical record was reviewed on 8/9/22 at 11:16 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, anxiety, delusional disorder, psychotic disorder with hallucinations and schizoaffective disorder. Current physician orders included, but were not limited to the following: a. Buspar (anti-anxiety) 5 mg, one tablet three times a day for anxiety, the order date was 2/16/22. b. Risperdal (anti-psychotic) 0.5 mg (milligram), one tablet at bedtime for psychotic disorder with hallucinations, the order date was 2/22/22. A 7/1/22 quarterly MDS (Minimum Data Set) assessment indicated she had moderate cognitive impairment and had not had any behaviors during the assessment period. She had received an anti-psychotic and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR (Gradual Dose Reduction). A current care plan, with a revised date of 8/8/22, indicated she exhibited verbal behavioral symptoms directed towards others such as, threatening others, screaming at others, cursing at others and name calling. Interventions included, but were not limited to, attempt to use diversion, distraction and reorientation to calm her, such as singing and talking with staff. A current care plan, with a revised date of 8/8/22, indicated she suffered from delusions (fixed false beliefs) due to dementia as evidenced by false beliefs building was on fire, a gas leak and son was her spouse. Interventions included, but were not limited to, gently explain that belief was false and introduce evidence to prove why it was not true and administer medications as ordered. A mood and behavior communication memo, dated 4/24/22 at 1:00 a.m., indicated she had made repetitive verbalizations and hallucinations, thought there was a dog and kept yelling for the dog. Interventions attempted included toileting, provided liquids, quiet environment, snack, allowed her to vent her feelings and provided her reassurance and comfort, the behavior was unchanged. A mood and behavior communication memo, dated 5/9/22 at 4:00 a.m., indicated she had made negative statements, repetitive verbalizations and hallucinations she was getting bit by rats. Interventions attempted included toileting, placed in chair or bed and given time to calm and then re-approached, the behavior was unchanged. A mood and behavior communication memo, dated 5/19/22 at 3:00 a.m., indicted she had made negative statements, restlessness, repetitive verbalizations, repetitive concerns, verbally aggressive, rejection of care, socially inappropriate, hallucinations and delusions. She had refused to go to the bathroom, interventions attempted included provided relaxation technique and quiet environment, one on one, allowed her to vent feelings and redirection, the behavior was unchanged. A Social Service Assessment, dated 6/10/22, indicated psychotic disorder with hallucinations, anxiety, recurrent depressive episodes, Alzheimer's disease and attention/concentration deficit. Behavioral symptoms and and care plan implementation to address behaviors: delusional disorders and confusion. Care plans reviewed and updated. A Psychiatry Progress Note, dated 6/28/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Behavioral and psychological symptoms of dementia: history of visual hallucinations and delusional thoughts that cause fear, tearfulness and anxiety, none recently reported, symptoms appeared stable and continue Risperdal 0.5 mg every bedtime. A mood and behavior communication memo, dated 7/19/22 at 2:00 p.m., indicated crying/tearfulness and wanted to go home. One on one was provided with her as well as reassurance and comfort, the interventions did not change the mood or behavior. A Psychiatry Progress Note, dated 7/20/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Schizoaffective disorder: GDR- after reviewing current medication therapy as well as recent behaviors and discussion with DON (Director of Nursing), pharmacy, Administration, and Social Services, contraindicating any dose reduction of Risperdal as a reduction would likely increase symptoms of psychosis and anxiety, continued to have delusional thoughts about rats getting her that caused hear and anxiety. Delusional thoughts were less frequent. A mood and behavior communication memo, dated 7/20/22 from 6:00 to 10:00 p.m., indicated she had disturbed other residents by yelling out about seeing rats and worried about children playing in the street. Had been provided snacks and water, toileted, relaxation techniques, quiet environment, one on one, conversation of interest, time to calm then re-approach and redirection. Possible trigger: urinalysis results indicated an urinary tract infection, physician to be notified on 7/21/22. A Psychiatry Progress Note, dated 7/26/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Anxiety: symptoms appear stable, continue Buspar 5 mg three times a day. Schizoaffective disorder: symptoms appeared stable, continue Risperdal 0.5 mg every bedtime. During an interview, on 8/12/22 at 8:46 a.m., RN 14 indicated the resident usually sang and made happy noises, had yelled out that the building was on fire, re-directing and distracting her usually helped. Cross Reference F644 2. During an observation, on 8/9/22 at 3:16 p.m., Resident 33 was sitting in a chair in the lounge across from the nurses' station. On 8/11/22 at 8:56 a.m., he was assisted out of the shower room and into the lounge area. His clinical record was reviewed on 8/9/22 at 10:43 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, physical aggression, depression, anxiety and schizoaffective disorder. Current physician orders included, but were not limited to the following: a. Buspar 10 mg, one tablet three times a day for anxiety, the order date was 8/24/21. b. Risperdal 1 mg, one tablet twice a day for dementia with behavioral disturbance, the order date was 9/28/21. c. Zoloft (anti-depressant) 25 mg, one tablet daily along with a Zoloft 50 mg tablet to equal 75 mg daily for depression, the order date was 6/15/22. A 7/1/22 quarterly MDS assessment indicated he had severe cognitive impairment. He had not had any hallucinations or delusions during the assessment period. Physical behavioral symptoms directed towards others and rejection of care had occurred 1 to 3 days during the assessment period. He had received an anti-psychotic, anti-depressant and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR. A current care plan, with a revised date of 7/13/22, indicated he was at risk for delirium or acute confusion related to dementia and schizoaffective disorder as evidenced by inattention, disorganized thinking and altered level of consciousness. The interventions included, but were not limited to, monitor for signs or symptoms of delirium such as: inattention, disorganized thinking, altered level of consciousness, psycho-motor retardation and acute confusion and administer medications as ordered. A current care plan, with a revised date of 7/14/22, indicated he required the use of an anti-psychotic medication, Risperdal, to treat dementia with behaviors and schizoaffective disorder. Interventions included, but were not limited to, observe for change in mood or behavior. A current care plan, with a revised date of 8/8/22, indicated he presented with a primary diagnosis of dementia with behaviors and may exhibit any or all of the following mood and behavior challenges: aggressive behaviors, hitting other and pushing and grabbing. Interventions included, but were not limited to, encourage activities of interest such as: (List). The care plan did not list activities of interest. A current care plan, with a revised date of 8/8/22, indicated he exhibited physical behavioral symptoms directed towards others such as: pushing, grabbing and hitting others. Interventions included, but were not limited to, psychotropic medications as ordered. A Social Service Assessment, dated 6/15/22, indicated schizoaffective disorder, dementia with behavioral disturbance, physical aggression, depression and anxiety. Medications: Zoloft 75 mg for depression, Risperdal 1 mg for dementia with behavioral disturbance. A Psychiatry Progress Note, dated 6/15/22, indicated no behaviors or psychosis reported since last visit, no new concerns had been reported and appeared stable from a psychiatric standpoint. Schizoaffective disorder: symptoms appear stable, continue Risperdal 1 mg twice a day. A mood and behavior communication memo, dated 7/25/22 at 7:40 p.m., indicated he had been found in another resident's room and had been incontinent of bowel movement, uncooperative with care, was combative hitting staff and resisting shower, it took two CNA's to complete the shower and assist him to bed. A mood and behavior communication memo, dated 7/28/22 at 9:20 p.m., indicated he had removed his brief, staff attempted to put it back on him, and he punched staff in the arm, behavior unchanged after interventions attempted. A mood and behavior communication memo, dated 8/6/22 at 10:00 p.m., indicated he had been sleeping in a chair, staff woke him to offer toileting and he became physically aggressive, tried to assist him to bed, he refused to sit anywhere, had a bowel movement and refused to be changed, there had only been one staff member on the secure unit, interventions had been attempted but behavior was unchanged. During an interview, on 8/12/22 at 8:47 a.m., RN 14 indicated his behaviors were rejection of care, especially with incontinent care, give him time to calm the re-approach or change staff member typically was effective. During an interview, on 8/12/22 at 9:30 a.m., the Social Service Director indicated he did not have delusions, he did have aggression with care and rejection of care. Cross Reference F6443. On 8/9/22 at 11:26 a.m., Resident 5 was in his wheelchair in room, chin to chest. On 8/10/22 at 8:43 a.m., he was in his recliner in his room with his eyes closed, holding a cup in his left hand halfway to his mouth and a spoon in his right hand. On 8/10/22 at 1:45 p.m., he was in his recliner, asleep. On 8/11/22 at 10:15 a.m. he was asleep in bed with the room dark. On 8/12/22 at 8:07 a.m., he was up in his wheelchair in the dining area, eating breakfast. Resident 5's clinical record was reviewed on 8/9/22 at 10:37 a.m. Diagnoses included, but were not limited to, chronic systolic heart failure, dementia with behaviors, major depressive disorder, expressive language disorder, and mood disorder. Current physician orders included, but were not limited to, desvenlafax (anti-depressant) 50 mg daily, quetiapine (anti-psychotic) 25 mg in a.m. and 50 mg at bedtime, tramadol (pain medication) 50 mg twice daily, and divalproex (mood stabilizer) 500 mg three times daily. A 4/20/22, quarterly, MDS assessment indicated he was severely cognitively impaired and had a fluctuating behavior of disorganized thinking. He had no psychosis, but had verbal and physical behaviors 1-3 days of the assessment period. He required extensive assistance for mobility, transfers and hygiene. He had a current care plan problem, reviewed 8/8/22, of rejection of care such as medication, treatments, ADL assistance, and bathing. Interventions included, but were not limited to, approach from the front in a calm manner, call the resident by his name, explain the purpose of the visit, allow time to calm down and reapproach as needed, praise efforts, attempt to determine the reason for rejection and seek solutions if able, and limit distractions. The care plan lacked individualized interventions for the resident. A current care plan problem, reviewed 8/8/22, indicated he had agitation and aggression. Interventions included, but were not limited to, talk about vintage cars he has restored. A current care plan problem, reviewed 8/8/22, indicated he had physical behaviors of hitting. Interventions included, but were not limited to, allow to calm down, music, massage or exercise to calm, praise compliance, and psychiatric medications as ordered. The care plan lacked individualized interventions for the resident. A current care plan problem, reviewed 8/4/22, indicated he required the use of antipsychotic medication to treat dementia with behaviors and agitation/PBSD (psychological and behavioral symptoms of dementia). He had a failed dose reduction on 7/20/22. A current 8/8/22 care plan for daily preferences indicated it was somewhat important to the resident to have his daily preferences honored. He preferred to sleep in and go to bed at 11:00 p.m. A review of nurses notes and behavior memos indicated the following: On 5/3/22, he refused his medications. On 5/4/22, he spit out his medications. On 5/7/22, he struck staff in the face when they were removing his foot pedals. They went to get other staff to help lay him down and he tried hitting them as well. On 5/8/22 at 5:30 p.m., he started swinging at an aide while getting him ready for bed and was inches from hitting aide in the face. On 5/9/22, he was swinging at an aide, and kicking at her as well, during care. On 5/18/22, an order was received to decrease the desvenlafax to 50 mg daily. On 5/24/22, he was using expletives and hitting and kicking while staff was putting him to bed at 6:45 p.m. He eventually calmed down and allowed assist to bed and fell asleep. On 5/26/22 at 8:20 p.m., he refused his medications, and was balling up his fists and lunging forward. He attempted to knock the spoon of medications out of the nurses hand. A CNA took him to his room to put him to bed per his request, but he hit staff in the chest. A call was placed to the psychiatric nurse practitioner and a discussion was held regarding an inpatient psychiatric stay versus sending him to the emergency department. As of 9:30 p.m., he had been sitting in his room and had calmed down. When asked if he wanted to lay down, he yelled no. The behavior memo indicated the quetiapine was increased following a failed dose reduction. On 5/26/22 at 8:30 p.m., he had a behavior of hitting a staff member, refusing medications, and being verbally and physically aggressive. He refused to be assisted to bed. On 6/2/22, he refused his morning medications and raised his hand in a threatening manner and refused his bedtime medications. On 6/7/22, he hit a CNA in the stomach multiple times, squeezed a CNA's wrist and told the CNAs he was going to kill them. A 6/15/22 pharmacist note to the prescriber indicated the resident had dementia and an order for an anti-psychotic medication. In order to meet criteria for use of the medication, the resident must be deemed a danger to himself or others and have one of the following: mania or psychosis or behavioral interventions attempted or refusal of care. The document was signed by the NP with the notation he had psychological and behavioral symptoms of dementia. On 6/15/22, the quetiapine was changed to 25 mg twice daily and the divalproex was increased to 500 mg three times daily. On 6/18/22, he threw a water cup on staff during medication pass and refused his medications except the one for pain. On 7/13/22, he refused his bedtime medications and was agitated. On 7/7/22, he refused a shower or to get up. He swung on staff and hit her in face when gotten up for lunch. When the same staff member went to put him in his room after lunch, he tried to hit her again. On 7/13/22, he refused his bedtime medications. On 7/14/22, he refused a shower and ADL care; he indicated he was tired and in pain. A 7/20/22 psychiatric NP note indicated an acute visit for increased physical aggression since the reduction of quetiapine (on 6/15/22). He had no delusions or hallucinations. His symptoms of depression benefited from the quetiapine, and was increased to 25 mg in a.m. and 50 mg at bedtime and he was to continue the divalproex. His current diagnoses included, but were not limited to, psychotic disorder with delusions and schizoaffective disorder. On 7/20/22, he refused his bedtime medications. On 7/23/22, he was kicking and punching staff during cares. On 7/24/22, he hit a CNA in the chest during cares. A 7/26/22 psychiatric NP note indicated he had been combative and refused to eat or take his medications over the past week. He had no delusions or hallucinations. He had a diagnosis of schizoaffective disorder, depressive type, with increased signs and symptoms, but no recent reports of delusional thoughts. On 7/27/22, he refused restorative exercises. An 8/4/22 wound assessment indicated he had a 2.5 centimeter (cm) long (L) x 2.3 cm width (W) x 0.1 cm depth (D) abrasion to his right foot with a small serous exudate with slough and irregular edges. An 8/4/22 wound assessment indicated he had a 1.2 cm L x 1.3 cm W x 0.3 cm D skin tear to his right lateral foot with serous exudate and a yellow wound bed. On 8/9/22, he became physical during a shower and bit a CNA. The note indicated three CNAs were present during the shower. During an interview, on 8/12/22 at 9:02 a.m., CNA 31 indicated Resident 5 did not have any delusions or hallucinations, but did have lots of behaviors. He did not want to do things because of pain, but the nurses say they're managing his pain. Sometimes if you told him his family was coming to visit, he would allow care to be done. Other times, he just needed re-approached. During an interview, on 8/12/22 at 9:07 a.m., CNA 32 indicated the resident was confused. When he was approached about getting dressed, he would initially be okay with it, then he would change his mind. His foot wounds would upset him, and then he would become resistant to care. A lot of it was just his personality. During an interview, on 8/12/22 at 9:10 a.m., LPN 33 indicated the resident could sometimes is resistant to care and he may be grumpy and not get along with others. She was not aware of him seeing or hearing things. He may cuss you one minute, then smile and love you the next. During an interview, on 8/12/22 at 9:30 a.m., the SSD indicated the resident would cry at times, or think he was still in his old times. He would think his family was at the facility when they weren't or he had done things he shouldn't have. She was not aware of what the resident's signs of dementia were versus what his signs and symptoms of schizoaffective disorder were. He received the anti-psychotic medication for schizoaffective disorder. Review of a current facility policy titled ANTIPSYCHOTIC MEDICATION/GRADUAL DOSE REDUCTION, dated September 2017 and provided by the Nurse Consultant on 8/12/22 at 10:38 a.m., indicated the following: .Since diagnoses alone do not warrant the use of antipsychotic medications, the clinical condition must also meet at least one of the following criteria .The symptoms are identified as being due to mania or psychosis .delusions .The behavioral symptoms present a danger to the resident or to others .The symptoms are significant enough that the resident is experiencing one or more of the following: inconsolable or persistent distress .a significant decline in function; and/or substantial difficulty receiving needed care 3.1-37(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide ordered medications for 1 of 7 residents reviewed for medication use. (Resident 40) Findings include: Resident 40's clinical record was reviewed on 8/11/22 at 11:06 a.m. The resident was admitted to the facility on [DATE] and discharged [DATE]. Physician's admission orders for 6/1/22 included, but was not limited to, quetiapine (antipsychotic) 50 mg daily at bedtime. Progress notes dated 6/2/2022 from the Nurse Practitioner (NP) indicated quetiapine 50 mg was ordered. The medication administration record (MAR) lacked initials to indicate the resident was given the ordered quetiapine on 6/1/22. On 6/2/22, the initials were circled with a notation added to the back of the page which indicated the resident did not receive quetiapine due to a lack of supply. On 6/4/22 and 6/5/22 the initials were circled on the quetiapine order with a lack of documentation indicating why the initials were circled. The physician's orders lacked an order to hold the quetiapine or give an alternative during the resident's stay. The nurses' notes lacked documentation that quetiapine was not given. Documentation of pharmacy, physician, family, or Director of Nursing (DON) notification of quetiapine's unavailability was lacking. During an interview, on 8/11/22 at 2:22 p.m., the Nurse Consultant indicated when initials are circled on the MAR, there should be a note on the front or back of the page that indicated why a medication was not given. During an interview, on 8/11/22 at 2:56 p.m., the Nurse Consultant indicated she had spoken with the pharmacy. Quetiapine was not sent and was not in the emergency drug kit (EDK). Quetiapine was not given to the resident from 6/1/22 through 6/5/22 because of lack of supply. She indicated the DON usually followed up when medications were not available. If a medication is unavailable for greater than 72 hours, the chart is audited. During an interview, on 8/12/22 at 10:08 am., Registered Nurse (RN) 61 indicated if a medication was unavailable and not in the EDK, the physician must be notified to see if the medication can be held or if an alternative medication can be given until the medication was available. When a medication was not given, it was circled. Then, on the back of the MAR, a note was documented which contains the date, time, and reason the medication was not given. She indicated documentation of the medication unavailability should be documented in the nurses' notes with the physician and family notification. During an interview, on 8/12/22 at 11:07 a.m., RN 62 indicated if a medication was ordered and unavailable, it should be circled on the MAR and documented on the back of the MAR. The family and doctor should be notified. The pharmacy should be notified to check on the medication's status. She indicated sometimes a medication required preauthorization before being sent. The DON reviewed all medications that required preauthorization. A current policy, titled Medications, obtaining from pharmacy for new admissions and readmissions and provided by the Nurse Consultant on 8/12/22 at 10:38 a.m., indicated .This facility will implement measures to ensure medication is obtained for administration as soon as possible following resident admission . 3.1-25(a)

Based on observation, interview and record review, the facility failed to ensure residents did not receive psychotropic medications without indication for 3 of 6 residents reviewed for unnecessary medications (Residents 31, 33 and 5). Findings include: 1. During an observation, on 8/9/22 at 1:56 p.m., Resident 31 was lying in bed. On 8/10/22 at 9:51 a.m., she was lying in bed. On 8/11/22 at 8:58 a.m., she was sitting in a wheel-chair in the dining room. Her clinical record was reviewed on 8/9/22 at 11:16 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, anxiety, delusional disorder, psychotic disorder with hallucinations and schizoaffective disorder. Current physician orders included, but were not limited to the following: a. Buspar (anti-anxiety) 5 mg, one tablet three times a day for anxiety, the order date was 2/16/22. b. Risperdal (anti-psychotic) 0.5 mg (milligram), one tablet at bedtime for psychotic disorder with hallucinations, the order date was 2/22/22. A 7/1/22 quarterly MDS (Minimum Data Set) assessment indicated she had moderate cognitive impairment and had not had any behaviors during the assessment period. She had received an anti-psychotic and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR (Gradual Dose Reduction). A current care plan, with a revised date of 8/8/22, indicated she exhibited verbal behavioral symptoms directed towards others such as, threatening others, screaming at others, cursing at others and name calling. Interventions included, but were not limited to, attempt to use diversion, distraction and reorientation to calm her, such as singing and talking with staff. A current care plan, with a revised date of 8/8/22, indicated she suffered from delusions (fixed false beliefs) due to dementia as evidenced by false beliefs building was on fire, a gas leak and son was her spouse. Interventions included, but were not limited to, gently explain that belief was false and introduce evidence to prove why it was not true and administer medications as ordered. A mood and behavior communication memo, dated 4/24/22 at 1:00 a.m., indicated she had made repetitive verbalizations and hallucinations, thought there was a dog and kept yelling for the dog. Interventions attempted included toileting, provided liquids, quiet environment, snack, allowed her to vent her feelings and provided her reassurance and comfort, the behavior was unchanged. A mood and behavior communication memo, dated 5/9/22 at 4:00 a.m., indicated she had made negative statements, repetitive verbalizations and hallucinations she was getting bit by rats. Interventions attempted included toileting, placed in chair or bed and given time to calm and then re-approached, the behavior was unchanged. A mood and behavior communication memo, dated 5/19/22 at 3:00 a.m., indicted she had made negative statements, restlessness, repetitive verbalizations, repetitive concerns, verbally aggressive, rejection of care, socially inappropriate, hallucinations and delusions. She had refused to go to the bathroom, interventions attempted included provided relaxation technique and quiet environment, one on one, allowed her to vent feelings and redirection, the behavior was unchanged. A Social Service Assessment, dated 6/10/22, indicated psychotic disorder with hallucinations, anxiety, recurrent depressive episodes, Alzheimer's disease and attention/concentration deficit. Behavioral symptoms and and care plan implementation to address behaviors: delusional disorders and confusion. Care plans reviewed and updated. A Psychiatry Progress Note, dated 6/28/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Behavioral and psychological symptoms of dementia: history of visual hallucinations and delusional thoughts that cause fear, tearfulness and anxiety, none recently reported, symptoms appeared stable and continue Risperdal 0.5 mg every bedtime. A mood and behavior communication memo, dated 7/19/22 at 2:00 p.m., indicated crying/tearfulness and wanted to go home. One on one was provided with her as well as reassurance and comfort, the interventions did not change the mood or behavior. A Psychiatry Progress Note, dated 7/20/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Schizoaffective disorder: GDR- after reviewing current medication therapy as well as recent behaviors and discussion with DON (Director of Nursing), pharmacy, Administration, and Social Services, contraindicating any dose reduction of Risperdal as a reduction would likely increase symptoms of psychosis and anxiety, continued to have delusional thoughts about rats getting her that caused hear and anxiety. Delusional thoughts were less frequent. A mood and behavior communication memo, dated 7/20/22 from 6:00 to 10:00 p.m., indicated she had disturbed other residents by yelling out about seeing rats and worried about children playing in the street. Had been provided snacks and water, toileted, relaxation techniques, quiet environment, one on one, conversation of interest, time to calm then re-approach and redirection. Possible trigger: urinalysis results indicated an urinary tract infection, physician to be notified on 7/21/22. A Psychiatry Progress Note, dated 7/26/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Anxiety: symptoms appear stable, continue Buspar 5 mg three times a day. Schizoaffective disorder: symptoms appeared stable, continue Risperdal 0.5 mg every bedtime. During an interview, on 8/12/22 at 8:46 a.m., RN 14 indicated the resident usually sang and made happy noises, had yelled out that the building was on fire, re-directing and distracting her usually helped. Cross Reference F644 and F744 2. During an observation, on 8/9/22 at 3:16 p.m., Resident 33 was sitting in a chair in the lounge across from the nurses' station. On 8/11/22 at 8:56 a.m., he was assisted out of the shower room and into the lounge area. His clinical record was reviewed on 8/9/22 at 10:43 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, physical aggression, depression, anxiety and schizoaffective disorder. Current physician orders included, but were not limited to the following: a. Buspar 10 mg, one tablet three times a day for anxiety, the order date was 8/24/21. b. Risperdal 1 mg, one tablet twice a day for dementia with behavioral disturbance, the order date was 9/28/21. c. Zoloft (anti-depressant) 25 mg, one tablet daily along with a Zoloft 50 mg tablet to equal 75 mg daily for depression, the order date was 6/15/22. A 7/1/22 quarterly MDS assessment indicated he had severe cognitive impairment. He had not had any hallucinations or delusions during the assessment period. Physical behavioral symptoms directed towards others and rejection of care had occurred 1 to 3 days during the assessment period. He had received an anti-psychotic, anti-depressant and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR. A current care plan, with a revised date of 7/13/22, indicated he was at risk for delirium or acute confusion related to dementia and schizoaffective disorder as evidenced by inattention, disorganized thinking and altered level of consciousness. The interventions included, but were not limited to, monitor for signs or symptoms of delirium such as: inattention, disorganized thinking, altered level of consciousness, psycho-motor retardation and acute confusion and administer medications as ordered. A current care plan, with a revised date of 7/14/22, indicated he required the use of an anti-psychotic medication, Risperdal, to treat dementia with behaviors and schizoaffective disorder. Interventions included, but were not limited to, observe for change in mood or behavior. A current care plan, with a revised date of 8/8/22, indicated he presented with a primary diagnosis of dementia with behaviors and may exhibit any or all of the following mood and behavior challenges: aggressive behaviors, hitting other and pushing and grabbing. Interventions included, but were not limited to, encourage activities of interest such as: (List). The care plan did not list activities of interest. A current care plan, with a revised date of 8/8/22, indicated he exhibited physical behavioral symptoms directed towards others such as: pushing, grabbing and hitting others. Interventions included, but were not limited to, psychotropic medications as ordered. A Social Service Assessment, dated 6/15/22, indicated schizoaffective disorder, dementia with behavioral disturbance, physical aggression, depression and anxiety. Medications: Zoloft 75 mg for depression, Risperdal 1 mg for dementia with behavioral disturbance. A Psychiatry Progress Note, dated 6/15/22, indicated no behaviors or psychosis reported since last visit, no new concerns had been reported and appeared stable from a psychiatric standpoint. Schizoaffective disorder: symptoms appear stable, continue Risperdal 1 mg twice a day. A mood and behavior communication memo, dated 7/25/22 at 7:40 p.m., indicated he had been found in another resident's room and had been incontinent of bowel movement, uncooperative with care, was combative hitting staff and resisting shower, it took two CNA's to complete the shower and assist him to bed. A mood and behavior communication memo, dated 7/28/22 at 9:20 p.m., indicated he had removed his brief, staff attempted to put it back on him, and he punched staff in the arm, behavior unchanged after interventions attempted. A mood and behavior communication memo, dated 8/6/22 at 10:00 p.m., indicated he had been sleeping in a chair, staff woke him to offer toileting and he became physically aggressive, tried to assist him to bed, he refused to sit anywhere, had a bowel movement and refused to be changed, there had only been one staff member on the secure unit, interventions had been attempted but behavior was unchanged. During an interview, on 8/12/22 at 8:47 a.m., RN 14 indicated his behaviors were rejection of care, especially with incontinent care, give him time to calm the re-approach or change staff member typically was effective. During an interview, on 8/12/22 at 9:30 a.m., the Social Service Director indicated he did not have delusions, he did have aggression with care and rejection of care. Cross Reference F644 and F7443. On 8/9/22 at 11:26 a.m., Resident 5 was in his wheelchair in room, chin to chest. On 8/10/22 at 8:43 a.m., he was in his recliner in his room with his eyes closed, holding a cup in his left hand halfway to his mouth and a spoon in his right hand. On 8/10/22 at 1:45 p.m., he was in his recliner, asleep. On 8/11/22 at 10:15 a.m. he was asleep in bed with the room dark. On 8/12/22 at 8:07 a.m., he was up in his wheelchair in the dining area, eating breakfast. Resident 5's clinical record was reviewed on 8/9/22 at 10:37 a.m. Diagnoses included, but were not limited to, chronic systolic heart failure, dementia with behaviors, major depressive disorder, expressive language disorder, and mood disorder. Current physician orders included, but were not limited to, desvenlafax (anti-depressant) 50 mg daily, quetiapine (anti-psychotic) 25 mg in a.m. and 50 mg at bedtime, tramadol (pain medication) 50 mg twice daily, and divalproex (mood stabilizer) 500 mg three times daily. A 4/20/22, quarterly, MDS assessment indicated he was severely cognitively impaired and had a fluctuating behavior of disorganized thinking. He had no psychosis, but had verbal and physical behaviors 1-3 days of the assessment period. He required extensive assistance for mobility, transfers and hygiene. He had a current care plan problem, reviewed 8/8/22, of rejection of care such as medication, treatments, ADL assistance, and bathing. Interventions included, but were not limited to, approach from the front in a calm manner, call the resident by his name, explain the purpose of the visit, allow time to calm down and reapproach as needed, praise efforts, attempt to determine the reason for rejection and seek solutions if able, and limit distractions. A current care plan problem, reviewed 8/8/22, indicated he had agitation and aggression. Interventions included, but were not limited to, talk about vintage cars he has restored. A current care plan problem, reviewed 8/8/22, indicated he had physical behaviors of hitting. Interventions included, but were not limited to, allow to calm down, music, massage or exercise to calm, praise compliance, and psychiatric medications as ordered. A current care plan problem, reviewed 8/4/22, indicated he required the use of antipsychotic medication to treat dementia with behaviors and agitation/PBSD (psychological and behavioral symptoms of dementia). He had a failed dose reduction on 7/20/22. A current 8/8/22 care plan for daily preferences indicated it was somewhat important to the resident to have his daily preferences honored. He preferred to sleep in and go to bed at 11:00 p.m. A review of nurses notes and behavior memos indicated the following: On 5/3/22, he refused his medications. On 5/4/22, he spit out his medications. On 5/7/22, he struck staff in the face when they were removing his foot pedals. They went to get other staff to help lay him down and he tried hitting them as well. On 5/8/22 at 5:30 p.m., he started swinging at an aide while getting him ready for bed and was inches from hitting aide in the face. On 5/9/22, he was swinging at an aide, and kicking at her as well, during care. On 5/18/22, an order was received to decrease the desvenlafax to 50 mg daily. On 5/24/22, he was using expletives and hitting and kicking while staff was putting him to bed at 6:45 p.m. He eventually calmed down and allowed assist to bed and fell asleep. On 5/26/22 at 8:20 p.m., he refused his medications, and was balling up his fists and lunging forward. He attempted to knock the spoon of medications out of the nurses hand. A CNA took him to his room to put him to bed per his request, but he hit staff in the chest. A call was placed to the psychiatric nurse practitioner and a discussion was held regarding an inpatient psychiatric stay versus sending him to the emergency department. As of 9:30 p.m., he had been sitting in his room and had calmed down. When asked if he wanted to lay down, he yelled no. The behavior memo indicated the quetiapine was increased following a failed dose reduction. On 5/26/22 at 8:30 p.m., he had a behavior of hitting a staff member, refusing medications, and being verbally and physically aggressive. He refused to be assisted to bed. On 6/2/22, he refused his morning medications and raised his hand in a threatening manner and refused his bedtime medications. On 6/7/22, he hit a CNA in the stomach multiple times, squeezed a CNA's wrist and told the CNAs he was going to kill them. A 6/15/22 pharmacist note to the prescriber indicated the resident had dementia and an order for an anti-psychotic medication. In order to meet criteria for use of the medication, the resident must be deemed a danger to himself or others and have one of the following: mania or psychosis or behavioral interventions attempted or refusal of care. The document was signed by the NP with the notation he had psychological and behavioral symptoms of dementia. On 6/15/22, the quetiapine was changed to 25 mg twice daily and the divalproex was increased to 500 mg three times daily. On 6/18/22, he threw a water cup on staff during medication pass and refused his medications except the one for pain. On 7/13/22, he refused his bedtime medications and was agitated. On 7/7/22, he refused a shower or to get up. He swung on staff and hit her in face when gotten up for lunch. When the same staff member went to put him in his room after lunch, he tried to hit her again. On 7/13/22, he refused his bedtime medications. On 7/14/22, he refused a shower and ADL care; he indicated he was tired and in pain. A 7/20/22 psychiatric NP note indicated an acute visit for increased physical aggression since the reduction of quetiapine (on 6/15/22). He had no delusions or hallucinations. His symptoms of depression benefited from the quetiapine, and was increased to 25 mg in a.m. and 50 mg at bedtime and he was to continue the divalproex. His current diagnoses included, but were not limited to, psychotic disorder with delusions and schizoaffective disorder. On 7/20/22, he refused his bedtime medications. On 7/23/22, he was kicking and punching staff during cares. On 7/24/22, he hit a CNA in the chest during cares. A 7/26/22 psychiatric NP note indicated he had been combative and refused to eat or take his medications over the past week. He had no delusions or hallucinations. He had a diagnosis of schizoaffective disorder, depressive type, with increased signs and symptoms, but no recent reports of delusional thoughts. On 7/27/22, he refused restorative exercises. On 8/9/22, he became physical during a shower and bit a CNA. The note indicated three CNAs were present during the shower. An 8/4/22 wound assessment indicated he had a 2.5 centimeter (cm) long (L) x 2.3 cm width (W) x 0.1 cm depth (D) abrasion to his right foot with a small serous exudate with slough and irregular edges. An 8/4/22 wound assessment indicated he had a 1.2 cm L x 1.3 cm W x 0.3 cm D skin tear to his right lateral foot with serous exudate and a yellow wound bed. During an interview, on 8/12/22 at 9:02 a.m., CNA 31 indicated Resident 5 did not have any delusions or hallucinations, but did have lots of behaviors. He did not want to do things because of pain, but the nurses say they're managing his pain. Sometimes if you told him his family was coming to visit, he would allow care to be done. Other times, he just needed re-approached. During an interview, on 8/12/22 at 9:07 a.m., CNA 32 indicated the resident was confused. When he was approached about getting dressed, he would initially be okay with it, then he would change his mind. His foot wounds would upset him, and then he would become resistant to care. A lot of it was just his personality. During an interview, on 8/12/22 at 9:10 a.m., LPN 33 indicated the resident could sometimes is resistant to care and he may be grumpy and not get along with others. She was not aware of him seeing or hearing things. He may cuss you one minute, then smile and love you the next. During an interview, on 8/12/22 at 9:30 a.m., the SSD indicated the resident would cry at times, or think he was still in his old times. He would think his family was at the facility when they weren't or he had done things he shouldn't have. She was not aware of what the resident's signs of dementia were versus what his signs and symptoms of schizoaffective disorder were. He received the anti-psychotic medication for schizoaffective disorder. Review of a current facility policy titled ANTIPSYCHOTIC MEDICATION/GRADUAL DOSE REDUCTION, dated September 2017 and provided by the Nurse Consultant on 8/12/22 at 10:38 a.m., indicated the following: .Since diagnoses alone do not warrant the use of antipsychotic medications, the clinical condition must also meet at least one of the following criteria .The symptoms are identified as being due to mania or psychosis .delusions .The behavioral symptoms present a danger to the resident or to others .The symptoms are significant enough that the resident is experiencing one or more of the following: inconsolable or persistent distress .a significant decline in function; and/or substantial difficulty receiving needed care 3.1-48(a)(1) 3.1-48(a)(4)

Based on observation, interview, and record review, the facility failed to ensure medications were securely and hygienically stored during 2 of 2 random observations of the 100 and 200 hall unit. Findings include: 1. During a random observation, on 8/8/22 at 9:19 a.m., a medication cart was observed unattended near the shower room on the 200 Hall with stacks of medication cards on top of it. The cards contained, but were not limited to, omeprazole capsules (for acid reflux), methotrexate (chemotherapy drug) 2.5 mg tablets, and quetiapine (anti-psychotic) 50 mg tablets. During an interview, on 8/8/22 at 9:23 a.m., RN 36 indicated she had been cleaning the cart out and had left the medications out. 2. During a random observation, on 8/10/22 at 9:48 a.m., the 100 and 200 Hall treatment cart was observed unlocked and unattended at the nurses station. During an observation of the cart, on 8/10/22 at 9:55 a.m., accompanied by the Regional Director/RN, the top drawer of the cart contained, but was not limited to, various open wound dressings with pieces cut out, urine test strips, Maxsorb (skin treatment) with no resident identifiers, diclofenac (anti-inflammatory) ointment, open and partially used phytoplex (skin protectant) ointment with no resident identifiers, and an open container of iodosorb (anti-microbial). During an interview, at the time of the observation, the Regional Director indicated the cart should be kept locked when not in use. Review of a current facility policy titled MEDICATION ADMINISTRATION, dated 4/2017 and provided by the Administrator on 8/12/22 at 8:45 a.m., indicated the following: .The top of a medication cart should be kept free of any hazardous material including medications .Always lock the medication cart before leaving it out of visual range 3.1-25(m)

Based on record review and interview, the facility failed to ensure laboratory orders were collected and completed for 2 of 5 residents reviewed for unnecessary medications (Residents 35 and 5). Findings include: 1. Resident 35's clinical record was reviewed on 8/9/22 at 11:25 a.m. Diagnoses included, but were not limited to, type 2 diabetes (insulin dependent), dementia with behavioral disturbance, and schizoaffective disorder. He had a current, 4/10/20, physician order for a hemoglobin A1C test (to measure average blood sugars) every three months in May, August, November, and February. The clinical record lacked test results or indication they had been completed. During an interview, on 8/12/22 at 10:16 a.m., the Nurse Consultant indicated the facility could not locate the test results. The resident had been in the hospital in July and had the test completed there, but it had not been completed as ordered. 2. Resident 5's clinical record was reviewed on 8/9/22 at 10:37 a.m. Diagnoses included, but were not limited to, chronic systolic heart failure, dementia with behaviors, major depressive disorder, expressive language disorder, and mood disorder. On 7/7/22, he had an order for a urinalysis with culture and sensitivity if indicated. There was no indication in the clinical record the specimen had been collected. On 7/28/22, he had an order for a urinalysis. Collection with intermittent catheterization was not successful. There was no indication in the clinical record the specimen had been collected. During an interview, on 8/9/22 at 10:16 a.m., the Nurse Consultant indicated the urinalysis tests had not been completed. Review of a current facility policy titled LABORATORY ORDERS, TIMELY DRAWS, dated 10/2014 and provided by the Regional Director on 8/12/22 at 11:13 a.m., indicated the following: Laboratory testing shall be conducted in a timely manner 3.1-49(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation, on 8/9/22 at 1:56 p.m., Resident 31 was lying in bed. On 8/10/22 at 9:51 a.m., she was lying in bed. On 8/11/22 at 8:58 a.m., she was sitting in a wheel-chair in the dining room. Her clinical record was reviewed on 8/9/22 at 11:16 a.m. She had admitted to the facility on [DATE]. Diagnoses included, but were not limited to, Alzheimer's disease, dementia with behavioral disturbance, anxiety, delusional disorder, psychotic disorder with hallucinations and schizoaffective disorder. Current physician orders included, but were not limited to the following: a. Buspar (anti-anxiety) 5 mg, one tablet three times a day for anxiety, the order date was 2/16/22. b. Risperdal (anti-psychotic) 0.5 mg (milligram), one tablet at bedtime for psychotic disorder with hallucinations, the order date was 2/22/2. A 7/1/22 quarterly MDS (Minimum Data Set) assessment indicated she had moderate cognitive impairment and had not had any behaviors during the assessment period. She had received an anti-psychotic and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR (Gradual Dose Reduction). A current care plan, with a revised date of 8/8/22, indicated she exhibited verbal behavioral symptoms directed towards others such as, threatening others, screaming at others, cursing at others and name calling. Interventions included, but were not limited to, attempt to use diversion, distraction and reorientation to calm her, such as singing and talking with staff. A current care plan, with a revised date of 8/8/22, indicated she suffered from delusions (fixed false beliefs) due to dementia as evidenced by false beliefs building was on fire, a gas leak and son was her spouse. Interventions included, but were not limited to, gently explain that belief was false and introduce evidence to prove why it was not true and administer medications as ordered. A Social Service Assessment, dated 6/10/22, indicated psychotic disorder with hallucinations, anxiety, recurrent depressive episodes, Alzheimer's disease and attention/concentration deficit. Behavioral symptoms and and care plan implementation to address behaviors: delusional disorders and confusion. Care plans reviewed and updated. A progress note, dated 6/15/22 at 4:00 p.m., indicated a new order to add a diagnosis of schizoaffective disorder. A Psychiatry Progress Note, dated 6/28/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Behavioral and psychological symptoms of dementia: history of visual hallucinations and delusional thoughts that cause fear, tearfulness and anxiety, none recently reported, symptoms appeared stable and continue Risperdal 0.5 mg every bedtime. A mood and behavior communication memo, dated 7/19/22 at 2:00 p.m., indicated crying/tearfulness and wanted to go home. One on one was provided with her as well as reassurance and comfort, the interventions did not change the mood or behavior. A Psychiatry Progress Note, dated 7/20/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Schizoaffective disorder: GDR- after reviewing current medication therapy as well as recent behaviors and discussion with DON (Director of Nursing), pharmacy, Administration, and Social Services, contraindicating any dose reduction of Risperdal as a reduction would likely increase symptoms of psychosis and anxiety, continued to have delusional thoughts about rats getting her that caused hear and anxiety. Delusional thoughts were less frequent. A mood and behavior communication memo, dated 7/20/22 from 6:00 to 10:00 p.m., indicated she had disturbed other residents by yelling out about seeing rats and worried about children playing in the street. Had been provided snacks and water, toileted, relaxation techniques, quiet environment, one on one, conversation of interest, time to calm then re-approach and redirection. Possible trigger: urinalysis results indicated an urinary tract infection, physician to be notified on 7/21/22. A Psychiatry Progress Note, dated 7/26/22, indicated dementia: no medication, continue appropriate behavioral interventions and psychotherapeutic communication. Anxiety: symptoms appear stable, continue Buspar 5 mg three times a day. Schizoaffective disorder: symptoms appeared stable, continue Risperdal 0.5 mg every bedtime. During an interview, on 8/12/22 at 8:46 a.m., RN 14 indicated the resident usually sang and made happy noises, had yelled out that the building was on fire, re-directing and distracting her usually helped. During an interview on 8/12/22 at 9:09 a.m., the Social Service Director indicted a PASRR (Preadmission Screening and Resident Review) referral for an evaluation and determination related to the new diagnosis of schizoaffective disorder had not been done because she had a diagnosis of dementia. 4. During an observation, on 8/9/22 at 3:16 p.m., Resident 33 was sitting in a chair in the lounge across from the nurses' station. On 8/11/22 at 8:56 a.m., he was assisted out of the shower room and into the lounge area. His clinical record was reviewed on 8/9/22 at 10:43 a.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, physical aggression, depression, anxiety and schizoaffective disorder. Current physician orders included, but were not limited to the following: a. Buspar 10 mg, one tablet three times a day for anxiety, the order date was 8/24/21. b. Risperdal 1 mg, one tablet twice a day for dementia with behavioral disturbance, the order date was 9/28/21. c. Zoloft (anti-depressant) 25 mg, one tablet daily along with a Zoloft 50 mg tablet to equal 75 mg daily for depression, the order date was 6/15/22. A 7/1/22 quarterly MDS assessment indicated he had severe cognitive impairment. He had not had any hallucinations or delusions during the assessment period. Physical behavioral symptoms directed towards others and rejection of care had occurred 1 to 3 days during the assessment period. He had received an anti-psychotic, anti-depressant and anti-anxiety medication everyday during the assessment period. The anti-psychotic had been received on a routine basis and there had not been an attempt of a GDR. A current care plan, with a revised date of 7/13/22, indicated he was at risk for delirium or acute confusion related to dementia and schizoaffective disorder as evidenced by inattention, disorganized thinking and altered level of consciousness. The interventions included, but were not limited to, monitor for signs or symptoms of delirium such as: inattention, disorganized thinking, altered level of consciousness, psycho-motor retardation and acute confusion and administer medications as ordered. A current care plan, with a revised date of 714/22, indicated he required the use of an anti-psychotic medication, Risperdal, to treat dementia with behaviors and schizoaffective disorder. Interventions included, but were not limited to, observe for change in mood or behavior. A current care plan, with a revised date of 8/8/22, indicated he presented with a primary diagnosis of dementia with behaviors and may exhibit any or all of the following mood and behavior challenges: aggressive behaviors, hitting other and pushing and grabbing. Interventions included, but were not limited to, encourage activities of interest such as: (List). The care plan did not list activities of interest. A current care plan, with a revised date of 8/8/22, indicated he exhibited physical behavioral symptoms directed towards others such as: pushing, grabbing and hitting others. Interventions included, but were not limited to, psychotropic medications as ordered. A progress note, dated 6/15/22 at 4:00 p.m., indicated a new order to add a diagnosis of schizoaffective disorder. A Social Service Assessment, dated 6/15/22, indicated schizoaffective disorder, dementia with behavioral disturbance, physical aggression, depression and anxiety. Medications: Zoloft 75 mg for depression, Risperdal 1 mg for dementia with behavioral disturbance. A Psychiatry Progress Note, dated 6/15/22, indicated no behaviors or psychosis reported since last visit, no new concerns had been reported and appeared stable from a psychiatric standpoint. Schizoaffective disorder: symptoms appear stable, continue Risperdal 1 mg twice a day. During an interview, on 8/12/22 at 8:47 a.m., RN 14 indicated his behaviors were rejection of care, especially with incontinent care. During an interview, on 8/12/22 at 9:30 a.m., the Social Service Director indicated he did not have delusions, he did have aggression with care and rejection of care. A PASRR referral for an evaluation and determination related to the new diagnosis of schizoaffective disorder had not been done because he had a diagnosis of dementia. They did not have a policy related to PASRR's, they use the federal requirements as reference. A review of frequently asked questions related to Indiana PASRR for providers, located on website https://maximusclinicalservices.com/sites/default/files/pasrr/documents/IN%20PASRR%20FAQ_S%202021%20-%204.21.21.pdf and dated 2020, indicated .22. When is a new Level I needed for a NF resident who admitted with a negative Level I PASRR approval? A negative Level I review is valid indefinitely, as long as there has been no change in mental health status Based on record review and interview, the facility failed to complete Preadmission Screening and Resident Review (PASRR) for residents newly diagnosed with mental illness for 4 of 7 residents reviewed for PASRR (Residents 19, 5, 31, and 33). Findings include: 1. Resident 19's clinical record was reviewed on 8/8/22 at 10:22 a.m. Diagnoses included, but were not limited to, depression, dementia, delusional disorder, schizoaffective disorder. She had a current, 7/29/21, care plan problem of delusions and hallucinations of things being wet such as her bed, blanket, briefs, or pants and the belief she was dying. Review of a PASRR level 1 assessment, dated 11/10/19, did not indicate mental health diagnoses were present. The assessment was not repeated after she was diagnosed with schizoaffecitve disorder on 7/29/21. 2. Resident 5's clinical record was reviewed on 8/9/22 at 10:37 a.m. Diagnoses included, but were not limited to, chronic systolic heart failure, dementia with behaviors, major depressive disorder, expressive language disorder, schizoaffective disorder, and mood disorder. Current physician orders included, but were not limited to, desvenlafax (anti-depressant) 50 mg daily, quetiapine (anti-psychotic) 25 mg in a.m. and 50 mg at bedtime, tramadol (pain medication) 50 mg twice daily, and divalproex (mood stabilizer) 500 mg three times daily. Review of an 8/24/21 PASRR Level 1 assessment indicated he had depression and dementia. He was prescribed divalproex and quetiapine for depression. He had no diagnoses related to schizoaffective disorder. During an interview, on 8/12/22 at 10:16 a.m., the Social Service Director indicated the residents had not had a new Level 1 PASRR assessment completed when they had been diagnosed with mental illness.