**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to ensure a transfer belt was used during a transfer for 1 of 2 residents (R30) reviewed for falls. This resulted in actual harm to R30 who sustained a left arm fracture. The facility implemented corrective action prior to the survey; therefore, the deficient practice was issued at past non-compliance. Findings include: R30's Fall Risk (Acuity) observation dated 7/16/24, identified R30 was at risk for falls. R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 was cognitively aware and had diagnoses that included blindness, type 2 diabetes, and hypertension (high blood pressure). R30 required partial/moderate assistance (helper did less than half the effort. Helper lifted, held or supported trunk or limbs, but provided less than half the effort) to walk 50 feet with two turns. R30's Physical Therapy (PT) Caregiver Education dated 3/11/25, identified R30 was able to complete sit to stand transfers from recliner in room to participate in lower extremity strengthening program but R30 would continue to require stand by assist (SBA) (refers to a caregiving approach where a caregiver remains close to a patient to ensure safety without providing physical assistance. This means the caregiver is ready to intervene if the patient loses balance or needs help during a task.) of one staff to contact guard assist (CGA) (a technique used in occupational and physical therapy where the therapist maintains light physical contact with the patient, typically at the hips or trunk, to provide safety without offering direct support. This method helps with body stabilization and balance, acting as a safety net to prevent falls while allowing the patient to perform movements independently.) of one staff for all mobility in the facility. R30's care plan revised 4/25/25, identified R30 is at risk for deterioration in transfer, walking in room, and walking in corridor, related to being a new resident and being blind. R30 was supervision/part assist with walking. R30 did not do steps due to her blindness. Sit to stand, transfers CGA/partial/moderate with one for safety depending on weakness and risk for unsteady gait. R30's untitled nurse aide care sheet undated, identified R30 used a cane with a gait belt for walk to dine. R30's resident progress note dated 6/4/25 at 2:48 p.m., identified R30 had a witnessed fall at 1:50 p.m. in day area hall. R30 was ambulating with cane and SBA. R30 lost balance and landed on her left side on floor. Stated hope I didn't break my left arm again. Large protrusion (bump) with a skin tear noted on left elbow. Stated moderate pain in area. At first R30 was very anxious about fall and with staff offered calm approach and encouraged deep breathing. R30 calmed down. R30 was sent to the emergency room with staff assist for evaluation. R30's resident progress note dated 6/9/25 at 2:27 p.m., R30 had a new diagnosis of left open ulnar (the ulna is a long bone found in the forearm that stretches from the elbow to the smallest finger, and when in anatomical position, is found on the medial side of the forearm. It runs parallel to the radius, the other long bone in the forearm, and is the larger and longer of the two) shaft fracture below elbow fusion hardware - due to fall last week - surgery completed on R30's left arm, R30 was not to remove dressing before follow up visit on 6/23/25. R30 was to be non-weight bearing with left upper extremity. Resident did not have any complications with surgery. During an interview on 6/9/25 at 2:02 p.m., R30 was sitting in her room recliner with her feet elevated. R30's left arm was wrapped in ace bandages, was in a sling and rested on a pillow. R30 stated she was walking in the hallway with a nursing assistant (NA) behind her and R30 really didn't know what happened but R30 and the NA could not catch her. R30 stated she broke her left arm and pointed to her forearm with her right hand. During an observation on 6/11/25 at 8:00 a.m., NA-B assisted R30 to walk to the dining room while NA-C followed behind with a wheelchair. R30 wore a gait belt around her waist and NA-B held onto the gait belt and remained close to R30. During an interview on 6/11/25 at 8:03 a.m., NA-B stated she was not at the facility when R30 fell but heard about it. R30 was walking with a nursing assistant, R30 stumbled and fell. NA-B stated she didn't know if R30 was wearing a gait belt or if the nursing assistant was holding the gait belt, but stated staff were expected to always use a gait belt when moving a resident to make it safe. During an interview on 6/11/25 at 8:04 a.m., NA-C stated she wasn't working when R30 fell and didn't know what happened. You always use a gait belt when you're walking someone. It just helps keep them steady in case the resident tripped. It was better to be safe than sorry. During an interview on 6/11/25 at 8:06 a.m., NA-D stated she was working the day R30 fell. NA-D was coming out of a room and heard a scream. R30 was walking with a nursing assistant and stumbled. You know how sometimes your feet stick to the floor? It was like that. NA-D stated she did not know if R30 was wearing a gait belt, but staff were always expected to use a gait belt when walking with a resident. During a phone interview on 6/11/25 at 8:18 a.m., registered nurse (RN)-B stated she was the nurse on duty the day R30 fell. RN-B was in the charting room when it happened. A nursing assistant was walking with R30 when it happened. RN-B stated she couldn't say if R30 was wearing a gait belt and/or if the nursing assistant was in close contact with R30 because she didn't see it happen. During an interview on 6/11/25 at 8:45 a.m., the director of nursing (DON) stated R30 was blind and was care planned to have CGA with walking. There was confusion to what CGA meant and the nursing assistant did not use a gait belt nor were they in close contact with R30. Since R30's fall, the DON had instructed staff to always use a gait belt for safety and had given education what SBA and CGA meant. On 6/11/25 at 10:00 a.m., a review of a surveillance video dated 6/4/25 at 1:54 p.m. to 1:55 p.m. was conducted with the DON. R30 was observed walking with a cane in her right hand with NA-A walking slightly behind her right side. R30 was not wearing a gait belt nor was NA-A in close proximity to R30. R30's stumbled and R30 fell forward, twisting on to her left side, landing on her left elbow/arm. The DON stated staff were expected to use gait belts and to follow care planned interventions to prevent/lessen the risk of falls. During an interview on 6/11/25 at 1:42 p.m., NA-A stated she was walking with R30 to the dining room for bingo and R30 lost her balance and fell. NA-A stated she tried to catch R30, but she just couldn't and R30 fell onto her left side. NA-A stated she didn't use a gait belt because R30 was steady and had never needed one. After R30's fall, the DON told staff they always had to use a gait belt when walking or moving residents for safety. The facility' corrective actions were confirmed through observation of staff using transfer belts along with staff interviews that identified staff knew to utilize a transfer belt for all transfers. The facility policy Fall Prevention Program revised 11/21, identified all staff members were responsible for implementing the intent and directives contained within this policy and creating a safe environment of care. Falls Prevention Plan: l. Universal fall precautions are to be implemented for all patients/residents admitted to Kittson Healthcare as they are aimed at keeping the care environment safe. Universal fall precautions include: a. Familiarize the patient with the environment. b. Have the patient demonstrate call light use. c. Maintain call light within reach. d. Keep the patient's personal possessions within patient safe reach. e. Have sturdy handrails in patient bathrooms, room, and hallway. f. Place the bed in a safe position when a patient is resting in bed; raise bed to a comfortable height when the patient is transferring out of bed. g. Keep bed brakes locked. h. Keep wheelchair wheel locks in locked position when stationary. i. Keep nonslip, comfortable, well-fitting footwear on the patient. j. Use night lights or supplemental lighting. k. Keep floor surfaces clean and dry. Clean up all spills promptly. l. Keep patient care areas uncluttered. m. Follow safe patient handling practices. II. An individualized care plan utilizing a multidisciplinary approach is to be created and implemented for each patient/resident identified as a fall risk. a. Members of the multidisciplinary team may include the attending physician, nursing, therapy, pharmacy, family, patient/resident or other members of the care team. b. The multidisciplinary team members will collaborate to address modifiable fall risk factors and implement interventions to try to minimize the consequences of risk that are not modifiable c. Interventions are to be patient/resident centered However, the policy failed to direct staff to use a gait belt with all resident transfers and/or ambulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were monitored for target behaviors, monitored for side effects, and educated on the risks/benefits of psychotropic use prior to initiation for 1 of 3 residents (R1) reviewed for unnecessary medications. This deficient practice caused actual harm when R1 experienced a decline in condition following the initiation and continued increase of a psychotropic medication. Findings include: R1's admission Minimum data set (MDS) dated [DATE], identified R1 was admitted on [DATE]. R1 had minimal difficulty in some environments with hearing, clear speech, and impaired vision, could see large print only. R1 sometimes understood others and responded adequately to simple, direct communication. R1's cognition was severely impaired with no behaviors. R1 required extensive assistance of two for toileting and extensive assistance of one for transfers, mobility, dressing, personal hygiene and supervision (oversight, encouragement, or cueing) for eating. R1's mobility devices included cane, walker, and wheelchair. R1 was frequently incontinent of bowel and bladder and was not on a toileting program. R1's diagnoses included non-brain traumatic syndrome, arthritis, and dementia. During the seven-day look-back period R1 received antidepressants five out of seven days and opioids (narcotics managed moderate to serve pain) six out of the seven days, and no antipsychotic medications were received. R1's psychiatric evaluation with nurse practitioner (NP) dated 7/3/23, identified concerns included anxiety and agitation secondary to Alzheimer's disease. R1 was identified as disoriented times four, sleepy throughout the appointment, fair eye contact, and does not answer questions coherently. R1 was disoriented to time, place, and situation and can be paranoid with delusional thinking at times. R1's insight and judgement were poor and deficits in both short- and long-term memory. NP recommended a trial of Rexulti 0.5 milligrams (mg) tablets orally daily times seven days then increase to 1 mg daily to target Alzheimer's dementia with agitation. Discussed risks and benefits with R1. R1's psychiatric medication management follow up with NP dated 7/17/23, identified R1 was last seen on 7/3/23, at that appointment was started on Rexulti for agitation secondary to Alzheimer's dementia. R1 remained disoriented times four, poor judgment, and deficits in both short- and long-term memory. Discussed typical course of treatment, treatment options, risks, and benefits discussed. Also discussed current/potential medications, their indications, and worst/most common side effects reviewed. Healthy lifestyle choices and coping skills reviewed and recommended. No indication a family representative attended the psychiatric appointments on 7/3/23, and 7/17/23, or the MD visit on 8/31/23. R1's quarterly MDS dated [DATE], identified R1's cognition remained severely impaired, and no behaviors identified in the seven-day look back period. R1's functional status had changed and R1 required extensive physical assistance of two staff for bed mobility, dressing, transfers, toilet assistance, and one-person physical assistance with eating. R1 was always incontinent of urine and no toileting plan used. R1's new diagnoses included Alzheimer's disease and anxiety disorder. R1 received antipsychotic, antidepressant, diuretic (reduced fluid buildup in the body), and opioid seven out of the seven days of the look back period. R1 had two falls with minor injuries. R1's care plan, last reviewed/revised 9/26/23, identified on 9/24/23, the use of Rexulti, psychotropic medication, was added along with possible side effects staff were directed to monitor for: drowsiness, dizziness, lightheadedness, shaking, increased appetite, weight gain, restlessness, and inability to keep still may occur. R1 was followed by medical doctor/director (MD) and pharmacy consultants, and the staff will dose change as ordered. Staff were directed to redirect daily, introduce self as necessary, offer cues as needed to maintain orientation level, allow R1 to make decisions as able, POA (power of attorney) to be contacted for financial decisions and family included on medical decisions. Additionally, staff were directed to have R1 included preferences in rendering care and services, encouraged and escorted to all group activities, praise involvement, informed R1 of upcoming activities and provided setting in which activities were preferred such as commons area and dining room, and varied the physical environment, when possible, outdoors on the Whitetail Square patio. Care plan lacked direction for frequency of side effect monitoring. R1's care sheet dated 9/25/23, identified R1 transferred independently, extensive assist of one partial bath and toileting. R1 very forgetful, fall risk, and may wander. Ambulation used a cane and assist of one and wheelchair for long distances. R1 may wander and needed redirection. Wander guard and hard of hearing (HOH) had hearing aids, did not wear them. Poor peripheral vision, look directly facing R1 when talking (had glasses did not wear them). R1 had arthritis in hand and ate a pureed diet. R1's Abnormal Involuntary Movement Scale (AIMS) dated 8/29/23, identified no involuntary movements noted after completion of the AIMS. Due to increase dose of Rexulti this a.m. R1 had some stiffness and reached out to things not there. Staff will monitor and notify provider if noted to worsen. R1's primary provider medical doctor (MD) visit dated 8/31/23, identified Plan: staff will notify psychiatry of R1's possible side effects from Rexulti were managing his psychotropic medications. R1 had dementia with behavioral issues can be combative and anxious. Rexulti was recently started, and staff notice he had some odd movements and posterior. They will notify NP who managed this. R1's physician's order dated 6/28/23, through 9/29/23, identified: -Start date 7/3/23, end date 7/9/23, Rexulti tablet 0.5 mg. Start 0.5 mg daily times seven days then increase to 1 mg daily one a day. Order written by psychiatric nurse practitioner (NP). -Start date 7/3/23, end date 7/19/23, Nurses please chart follow up on Rexulti effectiveness. Chart on effect on behaviors, and on side effects (e.g., drowsiness, dizziness, light headedness, hypotension, shaking, increased appetite, weight gain, restlessness, and inability to keep still. Provider will need notes from charting for follow up appointment on how to proceed with doses. Every shift; shift one, shift two, and shift three. -Start date 7/10/23, end date 7/17/23, increase Rexulti tablet 1 mg orally daily. Follow up appointment 7/17/23, at noon. Order written by medical doctor (MD). -Start date 7/17/23, through 8/25/23, Rexulti 1 mg daily with follow up appointment on 7/17/23, noon. Order written by NP-A. -Start date 8/25/23, through 9/28/23, Rexulti 2 mg orally once a day. Order written by NP. - 9/28/23, Rexulti take 1 mg tablet along with 0.5 mg tablet to equal 1.5 mg daily. (decrease) Ordered by MD. R1's monthly pharmacy review dated 9/6/23, included the following recommendations: NP please reassess the effectiveness of Rexulti on R1's behaviors versus risks and recent development of odd movements and posture. Could consider trying Divalproex (Depakote) (used to treat manic episodes associated with bipolar disorder and seizures). Although pharmacist consultant (PC) recommended a trial of Divalproex on 9/6/23, R1's medical record lacked documentation of a response to the request and side effect monitoring. R1's progress notes from 6/6/23, through 7/2/23, identified: -6/6/23, resident admitted to facility. -6/8/23-6/18/23 progress notes identified R1 had two falls, attempted to self transfer, was observed urinating behind door and attempted to inappropriately touch staff. -6/20/23, resident needs frequent one to one, up and down from wheelchair and interventions were mostly ineffective. -6/24/23, ambulated with walker and staff assist, played harmonica, and sang. Resident needed multiple reminders today to not self-transfer. -6/26/23 at 5:21 p.m., self-transferring, striking and hollering out. -6/28/23, Care Conference for resident - no real concerns noted, resident enjoys walking. -7/1/23, resident combative, hollering out in hallway, yelled someone help me', very angry and irritable. Resident was swinging at staff, spit in their faces, and tried to bite them. Resident got a hold of a gait belt and was flinging it into the air trying to hit staff with it. Tried to remove it from his hands but unable. Called MD on call and ordered 1 mg of Ativan. -7/2/23 at 1:30 a.m. Resident appeared calm. -7/2/23, hollering back and forth with other resident, calling him names, making threats, kicked and spit on staff. R1's records lacked assessments or behavioral notes addressing concerns related to R1's incidents on 6/26/23, 7/1/23 or 7/2/23, additionally, no new interventions were identified to assist in managing the behaviors. R1's progress notes from 7/3/23, through 9/29/23, identified: -7/3/23 at 3:33 p.m. provider phone orders follow up diagnosis agitation in Alzheimer's disease: start Rexulti 0.5 mg daily times seven days, then increase to 1 mg orally daily. Take at noon. Follow up appointment 7/17/23, at noon. Nurses, please chart follow up on medication effectiveness. Chart on effect on behaviors, and also side effects (e.g. drowsiness, dizziness, lightheadedness, hypotension, shaking, increased appetite, weight gain, restlessness, and inability to keep still. Provider will need notes from charting for follow up appointment on how to proceed with doses. R1's progress notes from 7/3/23-7/9/23 included a total of 8 total entries 3 of which indicated no adverse effects, 3 identifying no aggressive behaviors, and 3 identifying sexual or aggressive behavior or both. Progress notes from 7/10/23-8/21/23 indicated: -R1's medical record lacked evidence of progress notes on 7/14/23, 7/16/23, 7/19/23, 7/20/23, 7/22/23, 7/23/23, 7/25/23, 7/26/23, 7/28/23, 7/30/23, 8/10/23, 8/11/23, 8/13/23, 8/14/23, 8/16/23, 8/18/23, and 8/19/23. -7/10/23 at 4:14 p.m. started on first dose of 1 mg today. R1 does not exhibit increased drowsiness or lethargy. No complaints from staff regarding inappropriate behaviors this shift, although he attempted self-transfer from his wheelchair about two times. No concerns regarding hypotension as his gait appeared to be steady during attempt. Cooperative during cares, takes him medications without protest without spitting out medications. No observations of delusional conversations. No other observations to note. -7/11/23 at 7:28 a.m. R1 had been lethargic for most of the shift. Hard to arouse, but irritable when woken up and cried out as if in pain. Very confused and hard to re-direct -7/12/23 at 10:51 p.m. agitated and defensive this evening -7/13/23 at 10:16 p.m. confused -7/15/23 at 4:27 a.m. slept in bed all night without behaviors. -7/17/23 at 3:18 p.m. NP-A here for follow up visit of Rexulti. This was started at 0.5 mg for seven days and then increased to 1 mg orally daily for seven days. Today it was decided by NP-A after reading the progress notes since start date through the 14 days to stay with the 1 mg orally daily. Follow up with NP in six weeks. -7/21/23 at 4:55 p.m. Alert and oriented, assist of one for ADLS, and transferred with wheelchair and assist of one. Incontinent of bladder and continent of bowel. Behaviors had improved since taking new medication but still could be sexually inappropriate with staff at times. R1 was walked in hallways when restless and seemed to help. R1 played harmonica for staff. -7/24/23 at 6:30 p.m. Inappropriate comment made to female staff. -7/24/23 at 9:02 p.m. R1 very restless, kept getting up form wheelchair to walk, redirected and close supervision at nurse's station to prevent falls. -7/27/23 at 3:17 p.m. R1 had been sleepy often in past couple days. Today R1 was wide awake at 7:00 a.m. Staff provided 1:1, walked R1, and played his harmonica. These approaches were somewhat effective and R1 needed frequent redirection throughout the shift. -8/3/23 at 8:10 p.m. R1 required extensive assistance of one to two for ADLS, propels self in wheelchair, and stand by assist for transfers and walks. R1 was set up only for meals and consumed 100%. R1 needed supervision at times, liked to joke with staff and enjoyed playing harmonica. R1 usually in a fair mood and able to make needs known. -8/5/23 at 6:44 p.m. R1 had inappropriate behavior and restlessness, redirected but short lived due to his dementia level. R1 needed frequent redirection. Offered snacks and fluids, liked to play harmonica and go for walks. All of these combined helped with his inappropriate behavior and restlessness. -8/17/23 at 1:44 p.m. Extensive assistance of one with transfers and stand by assist with locomotion on the unit. Gait appeared to be more unsteady. Some inappropriate behavior, confused behavior, speech observed but easily redirected. -8/20/23 at 6:25 p.m. Witnessed self-transferring fall. Gait more unsteady. -8/21/23 at 4:46 p.m. urinalysis to rule out UTI (urinary tract infection) for increase confusion prior to recent fall. UA results are negative, Rexulti ordered to be increased to 2 mg orally daily. -8/25/23, 11:05 a.m. Rexulti increased to 2 mg daily per NP-A for Alzheimer's dementia with agitation. Follow upon 9/25/23, at 10 a.m. -R1 records lacked evidence of progress notes from 8/26/23--8/29/23. -8/30/23 at 2:25 p.m. R1 slept until 11:30 a.m. Staff went to assist from bed, buckled knees and refused to stand. Staff stated it was like he did not understand direction. Two assist to transfer to chair. Required extensive with all cares. Extensive assist with meal intake. Staff reported he was experiencing twitches and reaching out into midair. -8/31/23 at 10:48 a.m. R1 seen by MD today on rounds. R1 answered questions about sleeping and eating, not always answering appropriately. MD indicated he would notify NP about increase of reaching for things in the air, and jerky movements when sitting up in wheelchair. No new orders currently. -9/1/23 at 2:13 p.m. FM-A requested to discontinue Rexulti, provider was contacted to reach out to family to discuss concerns. -9/4/23 at 4:40 p.m. R1 slept all weekend. R1 placed hand over forehead, possible headache, given Tylenol which seemed to be effective. R1 was unable to say or rate pain to tell where his discomfort was due to his dementia. R1 was awake today but not happy mood like normal when awake. R1 would not sing, placed hand over mouth when writer tried to administer medications, not drinking fluid like his normal self, just maintained a frown and closed his eyes. Noted staff had to feed him at meals and does not pick- up silverware. When silverware placed in R1's hand unable to hold onto it to get his food onto it. -9/5/23 at 1:30 p.m. R1's daughter, son, and wife visiting. Family had asked for a copy of medications R1 had taken. Requested and talked to assistant director of nursing (ADON) and ask how R1 was doing and questions about Rexulti. Explained to family started on Rexulti due to negative behaviors displayed, hitting, spitting, attempted to bite. They talked about negative things said about Rexulti on television and it was explained that R1 was followed by NP and was the one that prescribed the medication, was willing to talk to family and planned on contacting them to discuss the medication. -9/6/23 at 1:19 p.m. Therapy comments: staff report transfers primarily assist of one. If fatigued, they may use assist of two. No therapy needs currently. -9/6/23 at 10:04 a.m. R1 was extensive assist of one for activities of daily living (ADLS) and transfers. Incontinent of bowel and bladder at times. Was out for all meals, took all medications without difficulty, drank all supplements this evening, and no behaviors noted. -9/7/23 at 1:18 p.m. Extensive assistance with ADLS. Staff now feeds resident all meals. Transfers are assist of one and mobility was extensive assistance of one. R1 incontinent of bladder and continent of bowel. No mood changes or behaviors noted at this time. -9/8/23 at 3:13 p.m. Incontinent of bowel and bladder most of the time. No behaviors noted today. R1 now required feeding resident at all meals. -9/9/23 at 5:14 a.m. R1 required extensive assistance of one to two for ADLS and transfers. Incontinent of bowel and bladder. -9/9/23 at 3:21 p.m. R1 very tired today. No behaviors noted and wanted to rest at breakfast time, ate lunch and supper. Incontinent of bowel and bladder wore incontinent products. Unable to ambulate today due to issues with balance despite staff assisting him. -9/9/23 at 6:55 p.m. R1 pocketed food (ground meat) in cheeks at lunch today. Spit it all out on his napkin. Smooth food textures ate really well. Needs assistance with feeding at meals. -9/10/23 at 6:03 a.m. Incontinent of bowel and bladder. -9/10/23 at 3:28 p.m. More alert today. Incontinent of bowel and bladder. Unable to ambulate today could not follow direction to take steps and grab walker in front of him. -9/11/23 at 1:27 p.m. and 9:10 p.m. No behaviors. R1 required to be fed at all meals. Appetite fair. -9/12/23 at 4:07 a.m. No behaviors extensive assistance of two for ADLS and transfers. Incontinent of urine. -9/12/23 at 11:16 a.m. Quarterly assessment completed. R1 severely impaired cognition. No signs or symptoms of depression. R1 pleasant and spends a majority of his time sitting in the commons room. R1 liked to visit but most of the time will not visit with appropriate responses and was very confused but pleasant. Family was good support and visits often. -9/14/23 at 3:43 p.m. R1 required extensive assistance of two for ADLS and transfers. Incontinent of bowel and bladder most of the time. No behaviors noted today. R1 now required to be fed all meals and more verbal queuing. Appetite was fair most of the time, pleasant and smiled. -9/14/23 at 5:29 p.m. Offered to walk R1 three times so far since 7:00 a.m. and had not been active or strong enough to ambulate. -9/14/23 at 9:14 p.m. Mobility was in wheelchair and if awake enough can move around. Most of time staff needed to push R1 to destination. Appetite was poor and liquid intake fair. R1 has slept the evening shift in his wheelchair, refused to eat supper, drank three to four ounces of ensure. R1 did not ambulate this evening was too sleepy. R1 was incontinent of bladder, not able to feed self, does not talk, reaches out in the air looking for something, does not attempt to self-transfer from his wheelchair. May need a reduction in his medications. -R1 records lacked evidence of progress notes from 9/15/22, 9/16/23, and 9/17/23, 9/18/23 9/19/23, 9/20/23, and 9/21/23. -9/22/23 at 10:46 a.m., Screen form sent to therapy to assess safe transfers. Staff reported R1 needed one to three staff at times. Also assessing transfers into bath chair. Reported had been lowered to floor when getting up into the bath chair. R1 records lacked evidence of progress notes on 9/23/23. -9/24/23 at 4:37 p.m., R1 very sleepy. Attempted to get R1 up for meal, used sternum tub with no effect, will same meal and attempt later. -9/24/23 at 7:58 p.m., Able to get medication in and had four ounces of ensure. R1 records lacked evidence of progress notes for 9/25/23, and 9/26/23. -9/27/23 at 12:53 p.m. MD signed orders to decrease Rexulti to 1.5 mg daily. New order will be sent to drug store. -9/27/23 at 2:28 p.m. Activity staff played music for R1 and he clapped hands and legs started moving with activity staff. Activity staff will continue to visit and take R1 on walks in the halls or go on the patio as weather permits. No concerns. -9/28/23 at 12:31 p.m. in response to the decrease in Rexulti form 2 mg to 1.5 mg was signed by MD. Hoped medication would be delivered by courier today in early afternoon. The 2 mg has been discontinued. The facility failed to document side effects or target behaviors as ordered by the NP each day, evening, and night shifts on: 7/5/23, 7/6/23, 7/17/23, 7/18/23, 7/19/23, 7/20/23, 7/27/23, 7/28/23, 7/30/23, 7/31/23, 8/1/23, 8/2/23, 8/3/23, 8/4/23, 8/7/23, 8/8/23, 8/9/23, 8/10/23, 8/11/23, 8/13/23, 8/14/23, 8/15/23, 8/16/23, 8/18/23, 8/19/23, 8/20/23, 8/22/23, 8/23/23, 8/25/23, 8/26/23, 8/27/23, 8/28/23, 8/29/23, 9/6/23, 9/13/23, 9/15/23. 9/16/23. 9/17/23, 9/18/23, 9/19/23, 9/20/23, 9/21/23, 9/22/23, 9/23/23, 9/25/23, 9/26/23, and 9/27/23. The facility failed to document side effects or target behaviors as ordered by the NP each day and night shifts on: 7/8/23, 7/9/23, 7/10/23, 7/12/23, 7/13/23, 7/16/23, 7/25/23, 7/26/23, 8/5/23, 8/21/23, 8/30/23, 9/4/23, 9/7/23, 9/24/23, 9/28/23, and 9/29/23. No side effects assessment documented days, evening shift, and night shifts: 7/21/23, 7/25/23, 7/26/23, 7/27/23, 7/28/23, 7/29/23, 7/30/23, 7/31/23, 8/6/23, 9/1/23, 9/5/23, 9/9/23, 9/10/23. 9/11/23, and 9/14/23. The facility failed to document side effects or target behaviors as ordered by the NP each day and evening shifts on: 7/15/23, and 8/21/23. The facility failed to documented side effects as ordered by the NP on day and night shifts on 7/11/23. Progress notes lacked evidence from 7/3/23, though 9/28/34, a responsible party was contacted and informed in advance of the risks/benefits and receive informed consent prior to the start, increased doses, and decreased doses of the Rexulti. Additionally, R1's medical record lacked side effect and behavioral monitoring for the antipsychotic medication administered. During an observation on 9/27/23 at 1:07 p.m., R1 sat in wheelchair with gripper socks on both feet without footrests on in commons area. R1 was hunched over, eyes were open and was observed to reach out into mid-air and attempt to grab something (that was not there) then flung his left hang/arm out wards numerous times. At 1:10 p.m. R1 reached out, leaned forward down to floor hunched over, and tried to touch and pick up something (that was not there) on the floor. At 1:15 p.m. a staff member came over to R1 and asked him to be her helper with colored pens, placed a pack of pencils in R1's hands and pushed him down the hallway. R1 did not respond to the staff member with words. During an observation on 9/27/23 at 3:30 p.m. R1 sat in wheelchair with eyes open looking around in commons area. R1 reached out into midair with his right hand and tried to grab something not there twice during this observation. During an observation on 9/28/23 at 9:00 a.m., R1 was pushed into the dining room in wheelchair by nursing assistant (NA-E) and placed at a table. NA-E placed a cloth protector on R1's chest and offered bites of hot cereal with a spoon. R1 was unable to open his mouth for the spoon to be placed. NA-E poured the hot cereal into a plastic cup and R1 was able to drink/swallow 50 % of the hot cereal and water offered. R1 appeared sleepy during this observation and given many cues by NA-E. At 9:30 a.m. NA-E removed R1's cloth protector from chest and pushed R1 down the hallway to the commons area. NA-E placed R1 in front of the television and put brakes on wheelchair. R1's head hung down and eyes were closed, and NA-E walked away. No verbal conversation was heard by R1 or behaviors noted. During an observation on 9/29/23 at 10:41 a.m., NA-C and NA-B located in tub room with R1 with door closed. R1 sat on tub chair awake without clothes on. NA-C placed lotion on R1's legs and R1 stated you got lotion and smiled. RN-B entered the tub room and stated R1 seemed more awake today which may be because he had not received Rexulti medication yesterday and had been placed on a new decreased dose that the pharmacy had not yet delivered. R1 conversed with NA-E and NA-B, appeared confused, and pointed at things that were not there. NA-C placed a gait belt around R1's waist. Together NA-C and NA-B stood on each side of R1, placed their hand underneath the gait belt and instructed R1 to stand up. R1 leaned forward but was unable to follow directions and could not stand up. NA-C reminded R1 he needed to stand up so that he could be transferred from tub chair to his wheelchair and placed R1's right hand on wheelchair arm rest and R1 was unable to follow directions and hands slide off arm rest. NA-C positioned himself in front of R1 with his legs touching his knees, took hold of the transfer belt from both sides, and instructed R1 to stand up. NA-C lifted R1 off the wheelchair with the gait belt and supported R1's knees so he stood up and then pivoted R1 into his wheelchair. No behaviors were noted during observation. During interview on 9/28/23, at 11:40 a.m., family member (FM)-A stated R1 walked with assist of one and was unstable on his feet when admitted on [DATE]. FM-A stated about a month after R1 was admitted to the facility he was unable to recognize family and we noticed a change in his cognitive abilities. FM-A stated he reminded R1 who they were, during visits and noted he had short fleeting ability to recognize family and was gone in an instant. FM-A stated R1 was agitated when he could not see a familiar face, but the facility placed him on Rexulti so quickly and without their knowledge or consent. FM-A also stated when they visited R1 started to ramble, and they were unable to understand what he was talking about. FM-A stated the Rexulti may have had some calming affects but in their opinion, it had deterred good parts of R1 while on it. FM-A indicated the facility had jumped the gun prior to him being placed on the Rexulti and really needed to get to know him better. FM-A stated they found out R1 was on a new medication over one week after he had started the medication and were informed by a nurse during a visit. They had never been given information about drug, risk and benefits and never provided the facility consent to start administrating the medication. Additionally, FM-A was not given the possible side effects and R1's daughter-in-law, a retired nurse looked upside effects. FM-A indicated family had informed staff nurse on 9/1/23, they wanted R1's Rexulti discontinued, and a staff nurse indicated they were unable to take R1 off until a doctor was contacted. FM-A stated on 9/5/23, a copy of R1's medication list was requested and received. FM-A stated family was contacted two weeks ago on 9/18/23 (18 days later), informed NP would meet with them on 9/25/23, at 10:00 a.m. FM-A stated he had received a phone call from the facility the morning of 9/25/23, indicated the meeting with NP had been canceled, and rescheduled for 10/6/23, at 10:00 a.m. FM-A stated as of today 9/28/23, a doctor had not visited with the family and had been almost three months R1 had been on Rexulti (28 days since the family asked for the medication to be discontinued). FM-A stated the family was very concerned about R1's change in behavior since starting the medication such as his unsteady gait, required more assistance with cares and eating, increased weakness, and cognitive decline. During an interview on 9/27/23 at 1:23 p.m., nursing assistant (NA)-A stated R1 was admitted [DATE], walked with a cane with stand by assist (SBA) of one, alert and oriented, played harmonica and sang. NA-A stated R1 was able to carry on a conversation, used a wheelchair to get around, and sometimes became restless, and unsteady when he tried to get up by himself. NA-A indicted R1 was started on a medication called Rexulti approximately three months ago. NA-A stated noted changes in R1 quickly after the medication was started and the nurse told me it was his body adjusting to it, then the dose was increased. NA-A stated R1 displayed jerking movements, suddenly, his entire body jerked, jumped in his chair, and arms and legs would go. NA-A the jerking movements started approximately 1 ½ months ago. NA-A indicated families walked by him and asked if he was ok when they saw the jerking movements that occurred randomly and quite often and lasted only a short time. NA-A stated nursing was aware of these jerking movements many staff talked about it especially during report. NA-A stated R1's personality has diminished, does not laugh, poor eye contact, and seemed like R1 looked right through her. NA-A also stated had been difficult to get R1 to eat and drink fluids, had to be fed by staff, and once the food was placed in his mouth, he was unsure what to do with it. NA-A stated R1 was toileted with assist of staff but had changed to a check and change and off load every three hours. NA-A stated R1 was unable to reposition himself in the wheelchair. During an interview on 9/28/23 at 10:00 a.m. medical doctor (MD) stated R1 was seen last 8/21/23, and staff reported R1 was having side effects (reaching for things in midair and jerky movements). MD confirmed those are possible side effects of Rexulti and was concerning. MD stated the staff planned on contacting NP the following day as she was the primary prescriber. MD indicated when staff were concerned about side effects from Rexulti medication they would be expected to have notified NP. During a telephone interview on 9/29/23 at 10:46 a.m. PC stated R1's chart was reviewed last on 9/6/23, a progress note identified increased jerky movements and reached for things in the air. PC stated she recommended NP reassess the effectiveness of Rexulti on R1's behaviors versus risks and decent development of odd movements and posture. PC stated she suggested considering trying Depakote instead of Rexulti. PC stated she just visited with RN-B during a meeting on 9/27/23 and noted R1 also had drowsiness and so the MD decreased R1's Rexulti as the NP was gone. PC confirmed she was unaware if NP had assessed the recommendations from 9/6/23 yet or not. PC stated once the facility received the recommendations, she expected them to give them to the provider and then it would be up to the provider to follow through. During an interview on 9/28/23 at 2:20 p.m., NA-D stated R1 can no longer stand up, walk or have a conversation like he did when first admitted to the facility. NA-D indicated R1 was slumped over in the wheelchair most of the time, had a lot less energy, no longer tried to get up on his own, and was more resistant to cares. NA-D stated when R1 was admitted to the facility he used a cane and SBA (stand by assist) of one to ambulate, fed himself, played harmonica, sang songs, cracked jokes, then a few months ago his condition started to change and decline. NA-D stated R1 was unable to converse, speech did not make sense, mumbled, hard to understand, and poor eye contact started. NA-D stated the NAs were expected to document on behaviors, not sure it had been done though. NA-D also stated there was a spot in R1's medical record behaviors should have been documented every shift but had to know when to chart those behaviors and were they normal or not, was not clear. NA-D indicated was not informed as to what side effects NAs were expected to watch for. NA-D confirmed R1 tried to touch staff and intervention such as redirection and staff placed body in a position R1 was unable to be reached helped and R1 no longer did that anymore, but no other strategies or interventions were implemented. NA-D stated R1 currently became combative with cares and did not seem to understand fully what staff wanted to do with him. NA-D indicated they used redirection and when staff felt unsafe, had two staff when cares were completed. During an interview on 9/28/23 at 2:35 p.m. NA-B indicated they had seen changes in R1 especially the last two months. NA-B stated R1 use to feed himself with set up but now staff had to feed him and place his hot cereal in a cup so that he drank it. R1 was now unable to figure out how to eat with spoon, which is a significant decline. NA-B noted R1 to be drowsy and experienced unexpected body jerking movements while he sat in a wheelchair along with grabbing in the air with his hands and t[TRUNCATED]