Based on interview, record review, and facility policy review the facility failed to develop and implement a comprehensive, person-centered care plan and individualized interventions, as evidenced by not addressing ongoing behavioral symptoms and providing individualized comfort care interventions, despite a known history of psychotic and aggressive behaviors, which resulted in Resident #10 having frequent behavioral episodes, refusal of medications and food, and frequent combative interactions with staff.for one (1) of twenty-three (23) residents reviewed for care planning. Resident #10 Findings include: A review of the facility's policy titled, MDS (Minimum Data Set), CAA (Care Area Assessments), and Care Plan Documentation Policy, with a reviewed date of 01/24/24, revealed, . It is the purpose of this facility to provide documentation in the medical record for MDS, CAA, and care plan purposes . Discussion: . 6. The care plan will be updated on an ongoing basis with significant changes in interventions . A record review of Resident #10's Comprehensive Care Plan revealed Resident #10 had a MOOD care plan with interventions in place. The interventions, however were not all inclusive and aligned with all the Certified Nursing Assistant (CNA) documentation interventions indicated in the Behavior Monitoring Interventions for Resident #10. A record review of Resident #10's admission Record revealed the facility admitted the resident on 10/01/21 with diagnoses that included Bipolar Disorder, Psychotic Disorder with Hallucinations Due to Known Physiological Conditions, Psychotic Disorder with Delusions, and other cognitive disorders. A record review of the Behavior Monitoring and Interventions documentation for March 2025 revealed Resident #10 exhibited frequent and escalating behavioral symptoms, including physical aggression, verbal outbursts, and refusal of care. Behavioral episodes were documented on multiple dates across all shifts, including but not limited to 03/11, 03/13, 03/14, 03/15, 03/16, 03/17, 03/21, and 03/22, often involving grabbing, hitting, pushing, scratching, screaming, cursing, and threatening staff. The most frequently used interventions included redirecting the resident, providing food/drink, re-approach, and offering comfort measures such as massage or repositioning. However, the documented outcomes were consistently noted as either same (unchanged) or worsened. In addition, the intervention choices for the CNA documentation were not specific to Resident #10 and did not align with comprehensive care plan interventions. During an interview, on 03/17/25 at 1:25 PM, CNA #3 stated that Resident #10 is always confused and has daily behaviors. She explained that the resident is noncompliant with care and becomes aggressive during care. She confirmed the behaviors have been ongoing for many months. During an interview with the Director of Nursing (DON) on 03/18/25 at 1:00 PM, he explained that the facility provides psychiatric services. However, once a resident is placed on palliative or comfort care, psychiatric services are no longer offered. During an interview on 03/18/25 at 3:00 PM, Licensed Practical Nurse (LPN) #3 explained that Resident #10 had been in a prolonged state of psychosis since her Depakote was discontinued. The family requested the resident be kept on comfort measures only. She stated the only behavioral intervention in place is administration of anxiety medication. On 03/19/25 at 3:20 PM, during an interview with LPN #2, she explained that care plans are updated daily and used by staff to guide resident care. She reported that staff are expected to follow the care plan to meet residents' needs. On 03/20/25 at 9:00 AM, during an interview with the DON and Assistant DON, the DON acknowledged facility does not have a contract hospice agency and instead provides comfort measures following their own internal palliative care protocol, which includes administration of Ativan as needed. On 03/20/25 at 12:20 PM, during an interview with LPN #5, she reviewed Resident #10's care plan and confirmed it lacked detailed comfort care interventions. She noted the care plan did not outline specific interventions related to behavioral management or psychotropic medications. On 03/20/25 at 1:00 PM, during an interview with the Administrator, she acknowledged Resident #10's clinical decline and stated that she expects staff to complete care plans accurately and in a timely manner. She reported that all regulations regarding care planning should be followed.

Based on observation, interview, and record review, the facility failed to ensure the ongoing provision of behavioral health services for a cognitively impaired resident with severe, escalating behaviors following discharge from a behavioral health unit and despite continued aggression, delusions, and medication refusal, the facility discontinued behavioral health services without a documented rationale, contributing to ongoing physical aggression toward staff and others for one (1) of 23 sampled residents. Resident #10 Findings include: On 03/17/25 at 1:16 PM, during an observation and interview, Resident #10 pleasantly confused, verbalizing that she needed to go home. A record review of the admission Record revealed the facility admitted Resident #10 on 10/01/21 with diagnoses including Bipolar Disorder, Unspecified, Psychotic Disorder with Hallucinations Due to Known Physiological Conditions, Psychotic Disorder with Delusions, and Other Symptoms and Sign Involving Cognitive Function and Awareness. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/25 revealed Resident #10 required a Staff Assessment for Mental Status, which indicated a memory problem for short term memory, memory okay for long term memory, and moderately impaired for cognitive skills for daily decision making. A review of Section E revealed Resident #10 delusions, physical, verbal, and other behavior symptoms directed towards others during the (7) day look back. The behavior of Rejection of Care occurred daily. A record review of the Behavior Monitoring and Interventions documentation, completed by Certified Nursing Assistants (CNAs), for March 2025 revealed Resident #10 exhibited frequent behavioral symptoms, including physical aggression, verbal outbursts, and refusal of care. Behavioral episodes were documented on multiple dates across all shifts, including 03/01, 03/04, 03/09, 03/10, 03/11, 03/12, 03/13, 03/14, 03/15, 03/16, 03/17, 03/18, 03/19, and 03/20, often involving grabbing, hitting, screaming, cursing, and threatening staff. The interventions included redirecting the resident, providing food/drink, re-approach, and offering comfort measures such as massage or repositioning. However, the documented outcomes were consistently noted as either same (unchanged) or worsened. There was no documentation the CNA notified the nurse of the resident's behaviors or that the behaviors were unchanged or had worsened after attempting the documented interventions. A record review of the Medication Administration Record (MAR) for March 2025 revealed that Resident #10 refused medications except for Morphine and Lorazepam. Resident #10 received Lorazepam 03/01, 03/02, 03/03, 03/05, 03/06, 03/09 (twice), 03/10, 03/11, and 03/13 (three times), 03/14, 03/15, 03/16 (twice), 03/17, 03/18 (twice), and 03/19 (twice). Resident #10 received Morphine on 03/01, 03/02, 03/05, 03/06, 03/09, 03/10, 03/13 (three times), 03/14, 03/15, 03/16 (twice), 03/18 (twice), and 03/19 (twice). There is no documentation on the MAR indicating resident-specific behaviors, interventions, and effectiveness of interventions. A record review of the Social Services Quarterly Note dated 01/09/25 revealed Resident #10 had was irritable, agitated, refused meds, and resistant of care during brief changes and bath. It was noted that every day the resident exhibited restlessness and annoyance/short temper and had refused to eat. The note indicated Resident #10 has had a Change in status in her cognitive status, social interaction, mood status, behavioral status, and rejection of care/resident choices. The document also indicated that psychological/psychiatric services were currently indicated for the resident with documentation including Resident is seen by Psychiatric Nurse Practitioner (NP) (10/11 and 12/13/2024) for follow-up/medication review/support. A record review of the Physician's Order Sheet revealed Resident #10 had a Physician's Order, dated 08/29/2024 to send the resident to an emergency room for evaluation of increased behaviors, and another physician's order, dated 11/14/2024, to send the resident to a Behavioral Health Unit (BHU) for further evaluation. A record review of the BHU documentation Discharge Instructions, dated 9/10/24, and 11/23/24, revealed Resident #10 received treatment from an inpatient BHU. A record review of the Psychiatric NP visit documentation, dated 12/13/24, for Resident #10 revealed . Anxiety not controlled, Psychosis not controlled . often refuses medications due to paranoid ideations, believing meds have been poisoned . On 03/17/25 at 1:25 PM, during an interview with CNA #3, she stated that Resident #10 is consistently confused and exhibits daily behavioral symptoms. She explained that the resident is often noncompliant with care and becomes physically aggressive during care. CNA #3 added that these behaviors have been ongoing for several months. On 03/18/2025 at 11:15 AM, during an interview with CNA #3, she stated that Resident #10's behaviors include kicking, spitting, hitting, and smearing anything she can get her hands on, including food and feces. On the morning of 3/18/2025, Resident #10 threw a full tray on her during breakfast. On 03/18/2025 at 1:00 PM, during an interview with the Director of Nursing (DON), he stated the facility offers psychiatric services, but once the resident was on palliative or comfort care, those services were discontinued. He reported that Resident #10 had previously seen psych services but was removed from the caseload after transitioning to Comfort Measures Only. He stated that Resident #10 continues to experience behavioral outbursts, hallucinations, and delusions, and was sent to the BHU twice. He explained that after one of the BHU visits, medications including Depakote were discontinued due to high lab levels. Since that time, the resident experienced a significant decline, refusing medications and eating very little. On 03/18/2025 at 3:00 PM, during an interview with Licensed Practical Nurse (LPN) #3, she explained that Resident #10 had exhibited ongoing behavioral symptoms for several months and had remained in a prolonged state of psychosis following the discontinuation of Depakote. She reported that the resident had not consistently taken any oral medications for months; however, earlier that day, she was able to administer oral Morphine and Ativan. LPN #3 stated that while attempting to provide wound care to a skin tear on the resident's right forearm, Resident #10 became physically aggressive, striking her on the arm and using profane language. She reported that this type of behavior occurs regularly, and that facility management is aware. According to LPN #3, the Resident #10 often refuses oral medications, believing them to be poisoned and had knocked the medications out of her hand earlier that day. The physician had considered discontinuing all oral medications, but the resident's daughter requested that they be continued in case the resident became willing to take them in the future. LPN #3 further explained that Resident #10 routinely throws items at staff, including food, trash, and bodily fluids. That morning, the resident reportedly threw an entire breakfast tray at a CNA. LPN #3 stated that the family had requested the resident remain at the facility under Comfort Measures Only. On 03/18/2025 at 4:10 PM, during an interview with CNA #5, she explained that Resident #10 had consistently exhibited behavioral concerns, with some evenings being more challenging than others. She stated that providing care always requires at least two staff members due to the resident's behaviors. Even with the assistance of two CNAs, the resident often remains combative, frequently kicking, scratching, and pinching during care. CNA #5 added that while the resident can occasionally be distracted, these moments are brief, and the resident is generally not easily redirected. On 03/19/2025 at 10:05 AM, during an interview with LPN #4, she explained that Resident #10 exhibited ongoing behavioral symptoms, including scratching herself and staff, hitting, cursing, and throwing food and bodily waste at staff on a daily basis. She stated that earlier that morning, the resident refused all oral medications and became physically aggressive toward the CNA during breakfast assistance. LPN #4 reported that she was able to administer the resident's anxiety and pain medications using an oral syringe, which resulted in the resident calming somewhat afterward. On 03/19/25 at 12:15 PM, during an interview and observation of incontinence care for Resident #10, CNA #4 and CNA #6 reported that the resident has behaviors that occur on a near daily basis. Resident #10 was observed to be resisting care and fighting the CNAs. On 03/19/25 at 2:25 PM, during a follow up interview with the DON, he confirmed that Resident #10 had been transferred to a BHU on two occasions-once in September 2024 and again in November 2024-due to escalating behavioral concerns, refusal to take medications, and decreased oral intake. Following the last BHU admission, the resident's family elected to initiate comfort measures only, and the facility honored that decision. The DON stated that despite the transition to comfort-focused care, Resident #10 continued to exhibit frequent behavioral disturbances and remained noncompliant with oral medications and nutrition. He acknowledged that there had been no improvement in the resident's behaviors since returning from the BHU. The DON could not recall the specific recommendations provided at the time of discharge from the BHU but noted the facility opted to manage her symptoms through its Comfort Measures protocol using anxiety and pain medications. On 03/20/25 at 9:00 AM, during an interview with the DON and the Assistant Director of Nursing (ADON), the DON explained Resident #10 had become increasingly combative with all aspects of care. The DON also clarified that the facility does not contract with an external hospice agency; instead, they provide in-house palliative care under a comfort measures protocol, which includes the use of Ativan as needed. On 03/20/25 at 10:40 AM, during a phone interview with Resident #10's granddaughter, she stated that both she and her mother are nurses and have been actively involved in the resident's care. She explained that over the past six (6) months to a year, there had been a noticeable decline in her grandmother's mental status. The resident had a longstanding history of mental health issues, including behavioral disturbances and dementia. She confirmed that Resident #10 had recently been admitted to a geriatric psychiatric facility on two (2) occasions. Following the most recent discharge, the resident initially showed slight improvement but quickly returned to her prior state. Based on the resident's continued decline and stated wishes, the family collectively agreed to place her on comfort measures only. The granddaughter shared that the resident continues to exhibit significant behavioral symptoms, including delusions, hallucinations, and verbal aggression. Due to the severity of these behaviors, family visits are often brief. She acknowledged that her grandmother consistently refuses medications and has poor nutritional intake but believes alternative behavioral medications or formulations could be explored. She confirmed awareness of the resident's significant weight loss but stated that the family made the decision not to pursue feeding tube placement. On 03/20/25 at 12:25 PM, during an interview with Social Services #1, she stated that she is part of the interdisciplinary team responsible for referring residents to behavioral health services. She acknowledged that Resident #10 had ongoing behavioral issues but reported that behavioral services were discontinued when the resident was placed on comfort measures. On 03/20/25 at 01:40 PM, during a phone interview with the Psychiatric NP, she explained that her services for Resident #10 were discontinued once the resident was placed on comfort measures. She stated that during her visits, Resident #10 often became upset and agitated by her presence, frequently refusing to participate in care. The NP shared that Resident #10 would regularly display aggressive behavior, including calling her derogatory names and exhibiting paranoid ideations. She noted that Resident #10 had been noncompliant with both care and medications for several months prior to the initiation of comfort measures and had experienced a noticeable decline in behavior. The NP consulted with colleagues due to the resident's worsening symptoms and it was eventually determined that her ammonia levels were elevated, prompting the discontinuation of Depakote. Although alternative medications were trialed, the resident continued to exhibit paranoid delusions and hallucinations. The NP confirmed that she was aware the resident was not taking prescribed medications, which contributed to the decision to begin comfort care. She stated that during her final visit in December 2024, Resident #10 was still experiencing uncontrolled anxiety and psychosis. She clarified that under the facility's palliative care approach, comfort measures are limited to managing symptoms without further psychiatric intervention.