Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded correctly for 1 of 1 resident reviewed for MDS accuracy. (Resident 28) Finding includes: The clinical record for Resident 28 was reviewed on 10/30/24 at 3:28 p.m. The diagnoses included, but were not limited to bipolar disorder, vascular dementia, intermittent explosive disorder, conduct disorder, and visual hallucinations. An annual MDS assessment, dated 12/14/23, indicated the resident had a diagnosis of bipolar disorder. A quarterly MDS assessment, dated 5/30/24, indicated the resident had a diagnosis of bipolar disorder. A quarterly MDS assessment, dated 8/20/24, indicated the resident had a diagnosis of bipolar disorder. The psychiatry nurse practitioner notes, dated 9/5/24 and 10/3/24, indicated the resident had a diagnosis of bipolar disorder. The assessment and plan indicated no changes to the current plan of care. A psychiatry nurse practitioner late entry note, dated 10/31/24, indicated incorrect documentation was struck out of the resident's Electronic Health Record (EHR) notes for 9/5/24 and 10/3/24. During an interview, on 10/31/24 at 9:16 a.m., the Administrator indicated Resident 28 did not have a diagnosis of bipolar disorder. The diagnosis was added in error to the MDS assessment and to the resident's EHR. During an interview, on 11/4/24 at 3:30 p.m., the MDS Coordinator indicated she coded the resident's MDS assessment incorrectly. The bipolar diagnosis was added to the resident's record in error. The MDS Coordinator could not find any documentation Resident 28 had a diagnosis of bipolar disorder. A current policy, titled MDS Supportive Documentation Policy, dated as revised 10/10/23 and received from the Administrator on 11/4/24 at 3:57 p.m., indicated .To accurately record the needs of our residents through MDS assessments, as required by federal regulations .Supportive Documentation in the medical record must be dated during the assessment reference period to support the MDS Responses .The Assessment Reference Date (ARD) is the last date for collecting MDS data .The Social Services Director will be responsible for the following CAA's and Care Plans: a. Delirium, b. Cognitive Loss/Dementia, c. Psychosocial Well Being, d. Mood State, e. Behaviors, f. Return to the Community/Referral 3.1-31(d)(3)

Based on interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for a resident identified as a high risk for elopement for 1 of 6 residents reviewed for accidents. (Resident 4) Finding includes: The clinical record for Resident 4 was reviewed on 10/29/24 at 4:10 p.m. The diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies (a type of dementia), anxiety, dementia without behavioral, psychotic or mood disturbance, and visual hallucinations. A wander risk evaluation, dated 10/8/24 at 4:13 p.m., indicated the resident had forgetfulness and/or a short attention span, had diagnoses of Alzheimer's and dementia with psychosis, was taking antipsychotics, and had a history of wandering. Her score was 11 which indicated she was at high risk for elopement. There was no comprehensive person-centered care plan in place for high-risk elopement. During an interview, on 11/4/24 at 4:00 p.m., LPN 5 indicated a care plan should have been developed. A current policy, titled Elopement, with a revision date of 8/10/22 and received from the Administrator on 11/4/24 at 3:30 p.m., indicated .a care plan will be developed with appropriate interventions implemented to provide for the resident's safety .an elopement binder will be kept and maintained on each unit and the front office 3.1-35(a) 3.1-35(d)(1)

2. During an observation of the medication cart on the 300-unit, on 10/30/24 at 11:09 a.m., the eye drops for Residents 4, 56 and 61 had no open dates on the outside container or the bottle containing the eye drops. a. The clinical record for Resident 4 was reviewed on 10/29/24 at 4:10 p.m. The diagnoses included, but were not limited to, neurocognitive disorder with Lewy bodies (a type of dementia), diabetic kidney disease, and long-term use of insulin. A physician's order, dated 10/3/24, indicated to instill Systane ophthalmic solution (for dry eyes) into both eyes. b. The clinical record for Resident 56 was reviewed on 10/29/24 at 4:27 p.m. The diagnoses included, but were not limited to, hypotension (low blood pressure), cachexia (weakness or wasting of the body), anorexia, Alzheimer's disease, and dementia without behavioral psychotic or mood disturbance. A physician's order, dated 8/22/24, indicated to instill Latanoprost (used for glaucoma) in both eyes at bedtime. c. The clinical record for Resident 61 was reviewed on 10/30/24 at 11:30 a.m. The diagnoses included, but were not limited to, generalized anxiety disorder, nutritional anemia, essential hypertension, cachexia, and obsessive-compulsive disorder. A physician's order, dated 10/1/24, indicated to instill Atropine sulfate ophthalmic solution every 2 hours as needed. During an interview, on 11/10/24 at 11:10 a.m., RN 4 indicated the eye drops would need to be reordered due to not having an open date. The manufacturers guidelines for Systane eye drops indicated to dispose of the drops 1 month after opening. The manufacturers guidelines for atropine sulfate indicated to dispose of the drops 28 days after opening. The manufacturers guidelines for Latanoprost indicated to dispose of the eye drops 6 weeks after opening. 3.1-25(j) 3.1-25(o) Based on observation, interview and record review, the facility failed to ensure medication carts were free of loose pills and to ensure staff labeled eye drops with an opened date in 2 of 3 medication carts reviewed for medication storage. (200-unit and 300-unit) Findings include: 1. During a medication cart observation with Registered Nurse (RN) 2, on 10/30/24 at 11:34 a.m., the 200-hall medication cart was observed to have the following: a. The bottom of the second drawer had one and a half loose white pills. b. The bottom of the third drawer had one loose white pill. During an interview, on 10/30/24 at 11:41 a.m., RN 2 indicated the loose pills should be destroyed when found in the bottom of the medication cart. During an interview, on 10/30/24 at 11:44 a.m., LPN 3 indicated when pills were found in the bottom of the carts, they should be removed and put in the container located in the medication room. During an interview, on 10/30/24 at 12:30 p.m., the Director of Nursing indicated loose pills should not be in the bottom of the medication cart. There should be no loose pills in the cart.

3. The record for Resident 20 was reviewed on 9/11/23 at 10:40 a.m. Diagnoses included, but were not limited to, chronic kidney disease, type 2 diabetes, Alzheimer's disease, and dementia. The residents weight log indicated the following weights: 1. On 4/3/23, the weight was 190.3 lbs. 2. On 4/10/23, the weight was 188.0 lbs. 3. On 4/17/23, the weight was 170.4 lbs. The resident had a 9.36% weight loss in 1 week. A care plan, dated 5/18/23, indicated the facility will weigh the resident each Monday. A care plan, dated 8/17/23, indicated to notify the MD (medical doctor) of any condition changes. During an interview, on 9/12/23 at 11:48 a.m., the DON (Director of Nursing) indicated the facility had not contacted the MD about the resident's weight changes until 4/26/23. The MD was not notified about the weight loss until 9 days later. A current policy, titled Weight Policy, revised on 10/12/22 and received from the DON on 9/11/23 at 10:54 a.m., indicated .Significant weight changes will be defined as: 5% in 30 days .Resident Representative and physician will be notified of significant weight changes A current policy, titled MD and Resident and/or Resident Representative Notification, revised on 7/1/22 and received from the Director of Nursing on 9/12/23 at 4:49 p.m., indicated .Inform the Resident, consult with the Resident's physician and notify the Resident's Representative when: A significant change in the Resident's physical, mental or psychosocial status .Even if a Resident is mentally competent, the Resident Representative will be notified of significant changes, unless otherwise specified according to the Resident's preference. Such preference will be included in the Resident's care plan A current policy, titled Medication Administration Schedule, revised on 5/23/23 and received from the Director of Nursing on 9/12/23 at 4:49 p.m., indicated .Administer right after resident eats. Do NOT give insulin if resident does not eat per medical director. If resident's blood sugar is 300 or greater then insulin may be administered prior to resident eating and if resident does not eat the meal. The employee must know this does not apply to medication prescribed for administration in accordance with meals or for medications such as insulin .Communicate with the physician to request orders be changed or discontinued as needed. 3.1-5(a)(2) Based on interview and record review, the facility failed to notify the physician of a blood glucose level greater than the physician's call orders and to notify the physician of a significant weight loss for 3 of 3 residents reviewed for notification. (Resident 38, 45 and 20) Findings include: 1. The record for Resident 38 was reviewed on 9/11/23 at 11:50 a.m. Diagnoses included, but were not limited to, type 2 diabetes mellitus, Alzheimer's, hypertension, and depressive disorder. A physician's order, dated 3/2/23, indicated to check blood glucose levels at 6:00 a.m., 12:00 p.m., 5:00 p.m., and 8:00 p.m. Notify the physician if blood glucose levels were greater than 400 or less than 60. A physician's order, dated 5/12/23, indicated to give Humalog Kwik pen insulin (used for high blood glucose levels) 12 units for a blood glucose level of 401-450 and notify the physician. A facility record for the resident's blood glucose levels indicated, on 7/6/23 at 5:15 p.m., the resident's blood glucose level was 407. There was no documentation the physician was notified of the blood glucose greater than 400. A care plan, dated 9/7/23, indicated the resident had a potential for fluctuating blood glucose levels related to insulin dependent diabetes. The interventions included, but were not limited to, treat the blood glucose levels according to physician orders and the facility policy. During an interview, on 9/12/23 at 3:01 p.m., LPN 3 indicated the resident's blood glucose level usually was high and had insulin for coverage. During an interview, on 9/12/23 at 3:16 p.m., LPN 3 indicated if the resident's blood glucose level was 400 or above the physician needed to be called. The nurse needed to find out if the physician had any additional orders. During an interview, on 9/12/23 at 3:49 p.m., the Director of Nursing (DON) indicated there were no notes notifying the physician. The physician needed to be notified of the blood glucose level greater than 400. During an interview, on 9/12/23 at 4:05 p.m., the DON indicated they called the physician to verify the call orders and the physician indicated he wanted to be called if the resident's blood glucose level was greater than 400. 2. The record for Resident 45 was reviewed on 9/13/23 at 3:55 p.m. Diagnoses included, but were not limited to, Alzheimer's, Crohn's disease (a chronic long-term disease which causes inflammation in your gastrointestinal (GI) tract), ileostomy (a surgically created opening in the abdominal wall through which digested food passes), and pressure ulcer stage 3. The resident had the following weights: 1. On 8/10/23, the weight was 126.6 pounds (lbs). 2. On 9/11/23, the weight was 115.7 lbs. The resident had an 8.61% weight loss in 1 month. A Nutritional at Risk (NAR) progress note, dated 8/16/23 at 9:39 a.m., indicated the resident was on weekly weights. The resident had a 12.3% weight gain in 180 days. There was no documentation of a significant weight loss of 8.61% in 1 month. The physician was notified, on 9/8/23, of a 12.6% weight gain in 6 months. The physician was not notified of the 8.61% weight loss from 8/10/23 to 9/11/23. A facility intake document, dated 7/1/23 to 8/28/23, indicated the resident's average meal intakes were 50 to 75%. The resident was offered alternate food choices and 0% intake was documented. A care plan, revised on 8/28/23, indicated the resident was at nutritional risk related to congestive heart failure, and Crohn's disease of large intestine. The interventions included, but were not limited to, provide ordered diet, and offer food substitutions, determine resident's preferences regarding additional nutritional support. During an interview, on 9/11/23 at 3:25 p.m., LPN 3 indicated the resident was a hit or miss when it came to eating. The staff encouraged the resident to eat meals and the resident ate approximately 50%. During an interview, on 9/13/23 at 3:00 p.m., the DON indicated the resident's weight did not trigger for a significant weight loss yet and it was not time to notify the physician of a weight loss. The resident was on NAR and was weighed weekly. The facility notified of physician, on 9/8/23, of a 12.6% weight gain in 6 months and not the significant weight loss.

Based on record review and interview, the facility failed to ensure the MDS (Minimum Data Set) quarterly review was correctly filled out regarding the PASARR (Preadmission Screening and Resident Review) for 1 of 1 resident reviewed for resident assessment. (Resident 7) Finding includes: The record for Resident 7 was reviewed on 9/11/23 at 11:10 p.m. Diagnoses included, but were not limited to, schizoaffective disorder, major depression, psychotic disorder, delusional disorder, and anxiety disorder. A PASARR level 1 screening outcome, dated 2/10/23, indicated there was no status change. An MDS assessment, dated 4/25/23, indicated the resident had not been evaluated by a PASARR level 2 and determined to have a serious mental illness or related illness. During an interview, on 9/7/23 at 11:14 a.m., the Administrator indicated a PASARR level 2 was done at the resident's previous facility, and they were never sent the PASARR level 2. The MDS was not marked for having a PASARR level 2 completed. During an interview, on 9/13/23 at 3:17 p.m., the DON indicated the facility did not have a MDS policy and followed the RAI (Resident Assessment Instrument) Manual. A current manual, titled Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, indicated .Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASARR determination 3.1-31(a) 3.1-31(d)

Based on interview and record review, the facility failed to recognize a significant weight loss for 1 of 4 residents reviewed for nutrition. (Resident 45) Finding includes: The record for Resident 45 was reviewed on 9/13/23 at 3:55 p.m. Diagnoses included, but were not limited to, Alzheimer's, Crohn's disease (a chronic long-term disease-causing inflammation in your gastrointestinal (GI) tract) and ileostomy (a surgically created opening in the abdominal wall through which digested food passes). A physician's order, dated 2/2/23, indicated the resident was on a regular diet and double portions or protein. A physician's order, dated 2/21/23, indicated the resident was to be given fortified food (foods with nutrients added to them to help boost their nutritional value) with supper. A physician's order, dated 4/13/23, indicated the resident was to be given fortified food with breakfast. A physician's order, dated 4/26/23, indicated the resident was to be given fortified food with lunch. The resident had the following weights: 1. On 8/10/23, the weight was 126.6 pounds (lbs). 2. On 9/11/23, the weight was 115.7 lbs. The resident had a 8.61% weight loss in 1 month. A Nutritional at Risk (NAR) progress note, dated 8/16/23 at 9:39 a.m., indicated the resident was on weekly weights. The resident had a 12.3% weight gain in 180 days. There was no documentation for the significant weight loss of 8.61% in 1 month. A facility intake document, dated 7/1/23 to 8/28/23, indicated the resident's average meal intakes were 50 to 75%. The resident was offered alternate food choices and 0% intake was documented. A care plan, revised on 8/28/23, indicated the resident was at nutritional risk related to congestive heart failure and Crohn's disease of large intestine. The interventions included, but were not limited to, provide ordered diet, and offer food substitutions, determine resident's preferences regarding additional nutritional support. During an interview, on 9/11/23 at 3:25 p.m., LPN 3 indicated the resident was a hit or miss when it came to eating. The resident ate approximately 50-75% of the meals. During an interview, on 9/13/23 at 3:00 p.m., the Director of Nursing (DON) indicated the resident's weight did not trigger for a significant weight loss and it was not time to notify the physician of a weight loss. The resident was on NAR and was weighed weekly. The facility notified the physician, on 9/8/23, of a 12.6% weight gain in 6 months and did not notify the physician of the significant weight loss. A current policy, titled Weight Policy, revised on 10/12/22 and received from the DON on 9/11/23 at 10:54 a.m., indicated .It is the policy of [name of facility] to identify residents who may be at nutritional risk due to weight change .Significant weight changes will be defined as: 5% in 30 days, 7.5% in 90 days and 10% in 180 days .Resident Representative and physician will be notified of significant weight changes 3.1-46(a)(1)

Based on interview and record review, the facility failed to submit a revised Preadmission Screen and Resident Review (PASARR) Level I after new mental health diagnoses were added for 2 of 4 residents reviewed for PASARR (Resident 12 and 38) Findings include: 1. The record for Resident 12 was reviewed on 9/21/22 at 3:18 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, psychotic disorder with delusions, hypertension, depressive disorder and chronic pain. A PASARR Level I, completed on 4/13/22, indicated no mental health diagnosis was known or suspected and no Level II was required. If changes occurred or new information refuted these findings then a new screen must be submitted. A physician's order, dated 7/7/22, indicated Seroquel (an antipsychotic) 50 mg (milligram) tablet, give 1 tablet by mouth daily. The diagnoses for the medication was psychotic disorder with delusions. 2. The record for Resident 38 was reviewed on 9/23/22 at 2:15 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, psychotic disorder with delusions, hypertension, depressive disorder and chronic pain. A PASARR Level I, completed on 10/8/18, indicated no mental health diagnosis was known or suspected and no Level II was required. If changes occurred or new information refuted these findings then a new screen must be submitted. A Behavior Management Evaluation, dated 8/4/22, indicated the resident had a diagnosis of delusional behaviors. During an interview, on 9/27/22 at 9:48 a.m., the Administrator and Director of Nursing indicated a PASARR Level II needed to be done if they were put on a psychotropic medication. During an interview, on 9/27/22 at 11:30 a.m., the Administrator indicated a new PASARR should have been completed when the antipsychotic medication was added. During an interview, on 9/27/22 at 12:53 p.m., the Director of Nursing indicated the facility did not have a policy on PASARR. 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure a resident needing assistance with ADL's (activity of daily living) was provided the scheduled daily showers for 1 of 5 residents reviewed for showers. (Resident 12) Finding includes: During an observation, on 9/19/22 at 2:34 p.m., Resident 12 was sitting in a recliner. The resident was covered with a blanket and his hair was greasy and not combed. During an observation, on 9/23/22 at 9:53 a.m., RN 8 was putting the resident's shirt back on. She indicated the resident could be difficult to provide care at times. The record for Resident 12 was reviewed on 9/21/22 at 3:18 p.m. Diagnoses included, but were not limited to, Parkinson's disease, hypertension, dementia with Lewy body dementia (affect chemicals in the brain), psychotic disorder with delusions. A care plan, dated 9/14/22, indicated the resident needed assistance with activities of daily living. The goal included the resident would be clean, fed and well groomed with assistance of staff. The MDS (Minimum Data Set) assessment, dated 4/20/22, indicated the resident needed one person physical assist with showers and bathing. A facility report, received from the Resident Care Manager (RCM) 9 on 9/27/22 at 3:15 p.m., indicated Resident 12 was missing 21 showers from 4/20/22 through 9/25/22. The report was marked did not occur on the missed showers. The resident's hair was shampooed 4 times between 9/4/22 through 9/25/22. During an interview, on 9/20/22 at 10:59 a.m., the resident's family member indicated the staff were short handed and they take a long time to get to him. He was supposed to get a shower two times a week and was not sure when he had one. During an interview, on 9/26/22 at 3:08 p.m., RCM 9 indicated, on 8/15/22, the facility started offering 3 showers a week. They had a care plan meeting and discussed the showers. The resident was receiving 2 showers per week on Wednesday and Saturday. It was very hard to give him a shower because of his Lewy body. A current policy, titled Activities of Daily Living (ADL's), dated as revised 5/15/17 and received from the Director of Nursing on 9/27/22 at 11:30 a.m., indicated .Assisting in activities of daily living are skills required in nursing as well as other professions such as nursing assistants. This include assisting in resident with personal hygiene, oral care, nail care, or toileting etc. (This list is not intended to be all inclusive) .Grooming/Personal Hygiene: Always allow residents to do as much as possible for themselves 3.1-38(a)(3)(B)

Based on interview and record review, the facility failed to recognize and notify the physician of a significant weight loss for 1 of 6 residents reviewed for nutrition. (Resident 29) Finding includes: The record for Resident 29 was reviewed on 9/24/22 at 2:42 p.m. Diagnoses included, but were not limited to, end stage renal disease (dialysis), shaft of left femur, chronic kidney disease, type 2 diabetes mellitus and hypertension. A physician's order, dated 9/1/22, indicated the resident was on a consistent carbohydrate diet, no added salt, avoid tomatoes, potatoes, oranges and bananas. A physician's order, dated 7/24/22, indicated the resident was on a 1500 ml (milliliter) fluid restriction, may have 180 ml at bedside, early morning 120 ml, breakfast 240 ml, lunch 240 ml, midday 120 ml with medication, supper 240 ml. A care plan, dated 7/27/22, indicated the resident had a potential for fluid volume deficit. The interventions included, but were not limited to, encourage fluid intake, provide assist with fluids and monitor indicators of hydration. The care plan did not include monitoring the resident's weights. A care plan, dated 7/27/22, indicated the resident was at a nutritional risk related to end stage renal disease, dependent on hemodialysis, therapeutic diet related to dialysis had a potential for fluid volume deficit. The interventions included, but were not limited to, obtain weight as ordered and offer substitutions as needed. The resident had the following weights: 1. On 8/1/22, the weight was 193.2 pounds (lbs.). 2. On 9/5/22, the weight was 174 lbs. The resident had a 9.95% weight loss in 1 month. A progress note, dated 9/21/22 at 12:07 p.m., indicated Physician 5 was notified of a 10.9% eight loss in 30 days. The physician was notified 17 days after the significant weight loss occurred. A current policy, titled Weight Assessment and Intervention, dated as revised on 7/08/22 and received from the Director of Nursing (DON) on 9/26/22 at 11:30 p.m., indicated .It is the policy of [name of facility] multidisciplinary team to prevent, monitor, and intervene for undesirable weight loss or gain for our residents .Any weight change of 5% in one month, 7.5% in 3 months, or 10% in 6 months or more since the last weight will be reweighed within 3 days to verify the weight .If a resident is on a fluid restriction due to excessive fluid intake the MD and Resident Representative will be notified of weight changes +/- 5lbs. Dialysis patients will be weighed daily or per physician order .Physician and resident representative will be notified of any significant weight change A current policy, titled Dining Services Policy and Procedure, dated 9/2022 and received from the DON on 9/26/22 at 11:30 p.m., indicated .To communicate nutritional monitoring tools used by dietary and IDT team .Nutrition Assessment will be completed upon admission and documented in the medical record .Resident weights will be monitored for significant unexpected change. (5% in 1 month, 7.5% in 3 months, 10% in 6 months). Appropriate intervention will be planned, implemented, reviewed and changed as needed until weight is stable . 3.1-46(a)(1)

4. The record for Resident 24 was reviewed on 9/21/22 at 4:30 p.m. Diagnoses included, but were not limited to, Fahr's disease (degenerative disease of the basil ganglia), dyskinesia (a movement disorder), and polyneuropathy (a malfunction of many peripheral nerves through out the body). A physician's order, dated 5/5/21, indicated to administer risperidone (an antipsychotic medication for schizophrenia) 0.5 milligrams twice daily for Fahr's syndrome. A physician's order, dated 5/18/21, indicated to reduce risperidone to 0.25 milligrams in the a.m., and 0.5 milligrams in the p.m., for 2 weeks, then re-evaluate verified medication usage for tremors. A physician's order, dated 12/31/21, indicated risperidone 0.25 milligrams twice daily for dyskinesia due to Fahr's disease. A fax, dated 5/25/22, was sent to the physician from the facility indicating the resident was having an increase in tremors. The response was to continue gradual dose reduction and the resident would be seen in 2 weeks. A fax, dated 6/8/21, sent to the physician from the facility indicated the resident was having worsening tremors and rolling of the right shoulder since the risperidone was stopped. The response from the physician was to continue to observe the worsening tremors. The physician indicated the symptoms were not prominent at a visit earlier in the day. A physician's note, dated 8/11/21 at 10:40 a.m., indicated the use of risperidone was for movement disorder in her right arm and shoulder. The risperidone was discontinued upon admission to the facility due to an unclear reason for the use of the medication. The physician also indicated the lack of familiarity with treating the movement disorder with risperidone. The use of risperidone seemed to be counterintuitive. A neurologist's progress note, dated 9/8/21 at 2:18 p.m., indicated the resident was referred due to right dyskinesia lasting for more than a year. Sinemet (an anti-Parkinson medication) 25/100 milligrams was started as a trial. A neurologist's note, dated 12/3/21 at 12:44 p.m., indicated the arm movement had worsened and increased. No symptom relief was noted from the use of Sinemet. The risperidone was restarted at a low dose of 0.25 milligrams twice daily. A physician's note, dated 12/14/22, indicated the risk versus benefits of risperidone were discussed with staff at the facility. He agreed with the restart of risperidone. During an interview, on 9/23/22 at 3:17 p.m., the Resident Care Manager indicated the resident was on risperidone and the medication was gradually decreased on admission due to an unclear diagnosis. The symptoms returned and she had an unsuccessful trial of Sinemet. During an interview, on 9/27/22 at 3:30 p.m., the pharmacist indicated the use of the risperidone for Fahr's disease was an off label use. 5. The record for Resident 40 was reviewed on 09/22/22 1:39 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, (mental confusion) impulse control disorder (failure to resist a temptation, urge or an impulse or having inability not to speak on a thought) and chronic kidney disease. A behavior note, dated 4/18/22, indicated the resident wandered into peers' rooms 5 times. The peers' did not seem affected by the wandering. The interventions included, but were not limited to, allowed resident to voice concerns, offered snack, provided 1:1, and walk with the resident. The outcome indicated the resident did not appear distressed. A behavior note, dated 5/20/22 10:24 a.m., indicated the resident had wandered into the doorway of 2 other residents rooms. She was offered snacks, provided 1:1 and assisted to walk around the facility. The interventions were effective. A psychiatric note, dated 7/7/22, indicated the staff reported increased wandering, reports she was waiting to go home, taking items from others rooms and reports of verbal aggression with staff. A failed dose reduction was noted due to the above behaviors. A physician's order, dated 7/7/22, indicated Divalproex (Depakote) 250 milligrams twice daily for impulse control disorder. A care plan, dated 8/22/22, indicated history of being sexually inappropriate related to dementia. Interventions included, but were not limited to, have 2 staff members when she was provided a bath, 1:1 visits to provide education regarding procedure and necessity. A care plan, dated 9/2/22, indicated refusals of care related to Alzheimer's disease. A care plan, dated 9/2/22, indicated disruptive behavior related to dementia, resident would urinate in the trash can, on plate covers, the floor or her meal tray rather than using the restroom. A care plan, dated 9/6/22, indicated impulse control disorder related to impulsiveness, manifested by yelling at staff and family and repeatedly calling son. During an interview, on 9/27/22 at 3:30 p.m., the pharmacist indicated the Depakote was being used off label. A recent publication of PDR.net (physicians desk reference) indicated .the approved use of risperidone was to treat schizophrenia, bipolar disorder, including acute mania or mixed episodes associated with bipolar 1 disorder in adults .the black box warning indicates antipsychotic's are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of risperidone in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .Seroquel (quetiapine) was indicated for the treatment of bipolar disorder, including mania, bipolar depression and major depressive disorder .the black box warning indicates antipsychotic's are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Seroquel in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .Zyprexa (olanzapine) was indicated for the treatment of schizophrenia .the black box warning indicates antipsychotic's are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Zyprexa in this population should be avoided if possible due to an increase in morbidity and mortality A recent publication of PDR.net indicated .Depakote was indicated for the treatment of bipolar disorder including mania .the black box warning indicates antipsychotic's are not approved for the treatment of dementia-related psychosis in geriatric patients and the use of Depakote in this population should be avoided if possible due to an increase in morbidity and mortality A current policy, titled Resident management of behavioral changes/concerns/modifications of behavior management plans/use of Psychotropic medications/prn use of psychotropic medications, with a revision date of 12/7/21 and received from the Director of Nursing on 9/27/22 at 11:30 a.m., indicated .a psychotropic drug affecting brain activity associated with mental processes and behaviors .these drugs include, but are not limited to .antipsychotics, antidepressants, antianxiety and hypnotics .necessary to treat a specific condition as diagnosed and documented in the clinical record 3.1-48(a)(4) Based on interview and record review, the facility failed to ensure the diagnoses were appropriate for the use of psychotropic medications for 5 of 5 residents reviewed for unnecessary medications (Residents 7, 12, 38, 24 and 40). Findings include: 1. The record for Resident 7 was reviewed on 9/23/22 at 10:34 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertension, impulse disorder, depressive disorder and dementia in other disease with behavioral disturbance and psychotic disorder with delusions. A physician's order, dated 7/28/21, indicated risperidone (an antipsychotic) 0.5 mg (milligram) by mouth twice a day for psychotic disorder with delusions (typically a symptom of mental disorder). A physician's order, dated 7/28/21, indicated risperidone (an antipsychotic) 0.25 mg (milligram) by mouth in the morning for psychotic disorder with delusions. A care plan, dated 9/19/22, indicated the resident had delusions, Alzheimer's disease and the resident received an antipsychotic medication. The resident was prescribed an antipsychotic medication to help manage behavior symptoms. Approaches included, but were not limited to, rule out delirium, assist the resident to call his wife and offer a snack. 2. The record for Resident 12 was reviewed on 9/21/22 at 3:18 p.m. Diagnoses included, but were not limited to, Parkinson's disease, hypertension, dementia with Lewy bodies, psychotic disorder with delusions. A physician's order, dated 7/7/22, indicated Seroquel (an antipsychotic) 50 mg tablet by mouth daily for psychotic disorder with delusions due to know physiological condition. A care plan, dated 9/14/22, indicated the resident was at a potential risk for side effect for antipsychotic medications. 3. The record for Resident 38 was reviewed on 9/23/22 at 2:15 p.m. Diagnoses included, but were not limited to, dementia with behavioral disturbance, psychotic disorder with delusions, hypertension, depressive disorder and chronic pain. A physician's order, dated 8/28/22, indicated Zyprexa (an antipsychotic) 2.5 mg tablet by mouth daily for psychotic disorder with delusions. A care plan, dated 8/20/22, indicated the resident had dementia with behavioral disturbance, a psychotic disorder with delusions. The resident was prescribed an antipsychotic medication to help manage behavior symptoms. Approaches included, but were not limited to, provide medication and avoid overstimulation.