Based on observation, record review, and interview, the facility failed to ensure a resident had a physician order to self-administer medications for one (#37) of one sampled resident reviewed for self-administration of medications. Corporate Nurse Consultant #1 identified there were no residents with physician orders to self-administer medications. Findings: Res #37 had diagnoses which included depression. A physician order, dated 01/24/24, documented trazadone HCL (antidepressant medication) 100 mg tablet by mouth at bedtime. There was no documentation the resident had physician orders to self-administer medications. An admission assessment, dated 01/31/24, documented the resident's cognition was moderately impaired. On 03/24/24 at 10:19 a.m., there was a round white tablet in a clear medicine cup observed on the resident's over the bed table. The resident stated the tablet in the cup was on their table after they returned to their room after breakfast. They stated they did not know what the tablet was or how it got there. On 03/24/24 at 10:26 a.m., LPN #1 was asked if the resident had physician orders to self-administer medications. They stated they did not. They were made aware the resident had a round white tablet in a medicine cup on their over the bed table. On 03/24/24 at 10:32 a.m., LPN #1 was observed removing the medicine cup from the resident's room. They stated the tablet looked like the resident's trazdone they received at bedtime. They stated the resident did not have a physician order to self-administer trazodone.

Based on observation and interview, the facility failed to ensure call lights accommodated residents needs for two (#10 and #37) of two sampled residents reviewed for accommodation of needs. The DON identified 53 residents resided in the facility. Findings: 1. Res #10 had diagnoses which included RA and type 2 diabetes mellitus. An admission assessment, dated 03/15/24, documented the resident's cognition was moderately impaired. It was documented the resident had impairment on both sides of their upper extremities. On 03/24/24 at 11:24 a.m., the resident stated they had to hold down the button on their call light to keep the call light activated. They stated they had their roommate activate their call light when needed. They stated their roommates call light was one where you pushed and pulled out the button. On 03/25/24 at 12:06 p.m., CNA #1 was asked what type of call lights the facility used. They stated they had the ones where you pushed the button down and the call light stayed on until the button was pushed up. They stated they did have a few call lights where you had to hold the button down to keep the call light activated. They were asked if Res #10 was able to use their call light. They stated the resident was not able to hold the call light button down. They stated the resident had their roommate push their call light. 2. Res #37 had diagnoses which included peripheral vascular disease, and unspecified symptoms and signs involving functions and awareness. An admission assessment, dated 01/31/24, documented the resident's cognition of moderately impaired. On 03/24/24 at 10:19 a.m., the resident stated they had to hold down the button on their call light to keep the call light activated. They stated their call light had been replaced, because the other one had a short in it. They stated they had their roommate activate their call light when needed. They stated they had one where you pushed the call button down and pulled it back up. On 03/25/24 at 12:12 p.m., CNA #2 was asked what type of call lights the facility used. They stated they had the ones where you pushed the button down and the call light stayed on until the button was pushed up. They stated they did have a few older call lights where you had to hold the button down to keep the call light activated. They were asked if Res #37 was able to use their call light. They stated the resident could hold the button down on their call light, but sometimes had their roommate activate their call light for them. On 03/25/24 at 12:30 p.m., corporate nurse consultant #1 was asked about the type of call lights the facility had. They stated as far as they knew there was only one type of call light. They stated they had the ones where you pushed the button down and the call light stayed on until the button was pushed up. They were made aware of the above observations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's code status was accurate for one (#21) of one sampled resident reviewed for advance directives. The DON identified 53 residents resided in the facility. Findings: Res #21 had diagnoses which included COPD, HTN, major depressive disorder, hyperlipidemia, osteoarthritis, PTSD, and chronic pain. A DNR Order Acceptance or Declination Report, dated [DATE], documented there was a copy of the resident's DNR order in their chart in the facility. A DNR consent form, dated [DATE], documented the residents gave consent for DNR. A physician order, dated [DATE], documented CPR. An admission assessment, dated [DATE], documented the resident's cognition was intact. On [DATE] at 10:07 a.m., the resident was asked about their code status. They stated they had signed a DNR and it should be on file with the facility. They stated they did not want CPR. On [DATE] at 10:23 a.m., LPN #2 was asked how staff determined what was a residents' code status if there was an emergency. They stated code status was the residents' preference. They stated they looked in the residents' chart. They were asked what was Res #21's code status. They stated they were a full code. They stated the resident had told them they were a DNR, but they did not have a DNR on file. LPN #2 was shown the resident had a signed DNR on file in their EHR.

Based on record review and interview, the facility failed to update the care plan related to hospice services for one (#17) of two sampled resident reviewed for hospice services. The DON identified 12 residents who received hospice services. Findings: Res #17 had diagnoses which included Alzheimer's disease, dementia, and congestive heart failure. A physician order, dated 10/31/23, documented to admit to hospice services related to a diagnosis of congestive heart failure. A significant change assessment, dated 11/10/23, documented the resident was severely cognitively impaired, required partial to moderate assistance with most ADLs, and received hospice services. A care plan, initiated 03/24/24, documented coordinated services between facility and hospice for end-of-life care. All interventions related to hospice care documented an initiation date of 03/24/24. On 03/26/24 at 1:17 p.m., MDS coordinator #1 stated the resident's care plan was not updated to include hospice services when the resident was admitted to hospice in October of 2023 but should have been. They stated the care plan was updated after the error had been found during an audit on 03/24/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to complete a discharge summary that included a recapitulation of the resident's stay for one (#55) of three sampled residents reviewed for discharge. The DON identified 53 residents resided in the facility. Findings: Res #55 discharged from the facility on 03/01/24. A Discharge summary, dated [DATE], did not document a diagnosis on discharge or a summary of the course of treatment in the facility. On 03/26/24 at 1:32 p.m., corp. nurse consult #1 stated the nurse should have filled out the recapitulation of stay portion of the discharge summary.

Based on record review and interview, the facility failed to ensure an antianxiety medication was monitored for effectiveness and side effects for one (#13) of five sampled residents reviewed for unnecessary medications. The DON identified 53 residents resided in the facility. Res #13 had diagnoses which included anxiety. A physician order, dated 12/07/23, documented to administer buspirone 10 mg three times per day for anxiety. A physician order, dated 03/24/24, documented to monitor side effects of antianxiety medications. On 03/26/24 at 9:04 a.m., corporate nurse consultant #1 was asked to provide documentation of side effect monitoring from 12/07/23 to 03/24/24. On 03/26/24 at 9:21 a.m., corporate nurse consultant #1 stated there was no documentation of side effect monitoring from December to March.

Based on observation, record review, and interview, the facility failed to ensure the physical environment was kept clean and maintained in good repair. The DON identified 53 residents resided in the facility. Findings: A facility policy and procedure titled Homelike Environment, revised 02/2021, read in part, .Residents are provided with a safe, clean, comfortable and homelike environment .The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect .homelike setting. These characteristics include .clean, sanitary . On 03/25/24 at 10:49 a.m., the womens visitor/staff restroom was observed. There was black residue on the inside area of the toilet bowl. On 03/25/24 at 10:57 a.m., the shower room on hall 200 was observed. There was black residue on the floor and the wall in the working shower stall. There was black residue on the inside area of the toilet bowl. On 03/25/24 at 10:59 a.m., the resident restroom on hall 100 was observed. There was a strong urine odor. There were floor tiles missing around the toilet. There was brown and yellow residue on the inside area of the toilet bowl. On 03/25/24 at 11:01 a.m., the shower room on hall 100 was observed. There was black and yellow residue on the floor and the walls in the shower stall. There was black residue on the inside area of the toilet bowl. There were floor tiles missing around the toilet and black residue was on the floor. There was material peeling off the ceiling and off of the wall around the hand sink. On 03/25/24 at 11:03 a.m., the shower room on hall 300 was observed. The floor drain cover in the shower stall was missing. There was black residue on the floor around the toilet. There was black residue on the inside area of the toilet bowl and there were multiple gnats flying around the toilet. On 03/25/24 at 11:07 a.m., the mens visitor/staff restroom was observed. There was black residue on the inside area of the toilet bowl. The base board was missing off the wall next to the entry/exit door. On 03/25/24 at 11:09 a.m., the laundry room was observed. There was an accumulation of lint on the washing machines and the dryers. There were pieces of sheetrock and an accumulation of white residue and lint on the floor behind the washing machines. The sheetrock was not sealed/finished near the window air unit. On 03/25/24 at 11:11 a.m., laundry aide #1 was asked how staff maintained the laundry room. They stated they cleaned daily. They stated maintenance concerns were reported to the maintenance department. 03/25/24 at 11:16 a.m., the housekeeping/laundry supervisor was asked how staff ensured the physical environment was kept clean and maintained in good repair. They stated staff cleaned daily. They stated there was a sheet at the nurses' station where they reported maintenance concerns. They were shown and made aware of the above observations. On 03/25/24 at 12:57 p.m., the COO, administrator, and corporate nurse consultant #1 were made aware of the above observations.

Based on observation, record review, and interview, the facility failed to conduct a thorough investigation into allegations of abuse for one (#38) of three sampled residents reviewed for abuse. The DON identified 53 residents who resided in the facility. Findings: An Abuse Policy, undated, read in parts, .Any allegation of abuse will be investigated by the Administrator and the Director of Nursing. The Administrator and the Director of Nursing will as a minimum: review the resident's medical record looking for events leading up to the incident, interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident (if cognitive ability permits), interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident if necessary, interview the resident's roommate, family members, and visitors as able and necessary, interview other residents to whom the accused employee provides care or services and review all events leading up to the incident .Witness reports will be reduced to writing with the witness signing and dating the report on the Witness Report form .The witness will write his/her own report . Res #38 had diagnoses which included nontraumatic intracerebral hemorrhage and dysphagia following cerebral infarction. An annual assessment, dated 10/10/23, documented the resident was severely cognitively impaired and required setup or clean-up assistance with mobility and most ADLs. An OSDH initial incident report form, dated 12/27/23, documented a CMA went into the resident's room and observed the resident kissing a facility employee. The report documented the incident was reported to law enforcement and APS. The report documented the employee was suspended pending an investigation. An OSDH notification of nontechnical service worker abuse, neglect, mistreatment or misappropriation of property report, dated 12/27/23 documented the employee had been suspended on 12/27/23. An OSDH final incident report form, dated 01/03/24, documented an investigation was completed and the employee confessed to the allegation. The report documented the employee was terminated. There was no documentation of an investigation related to the incident. On 03/24/24 at 11:50 a.m., Res #38 was observed sitting in their room. The resident stated they had never been sexually abused while residing in the facility. On 03/26/24 at 10:00 a.m., the administrator was asked for all documentation related to the investigation conducted for Res #38. The administrator stated the employee admitted to the allegation and was fired. They stated an attempt to locate additional documentation other than the OSDH incident forms would be made. On 03/26/24 at 10:23 a.m., the administrator stated camera footage was reviewed the day of the incident and the employee who witnessed the incident completed a witness statement. They stated the appropriate agencies were notified but an interview with Res #38, additional residents, and other staff members was not documented. The administrator stated the CMA witness statement could not be located. They stated the facility's abuse investigation policy was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a dialysis resident received monitoring before and after dialysis treatment and failed to ensure communication between the facility and the dialysis center for one (#13) of one sampled residents reviewed for dialysis. The DON identified one resident resided in the facility received dialysis services. Findings: Res #13 admitted on [DATE] with diagnoses which included end stage renal disease. Physician orders, dated 12/14/23, documented to obtain a weight before and after dialysis on Tuesday, Thursday, and Saturday. On 03/24/24 at 1:13 p.m., Res #13 was observed resting in their bed in their room. A white bordered adhesive dressing could be observed above the collar of their shirt on the right side of the chest below the collar bone. The resident stated the facility did not send any sort of communication form with them to dialysis. They stated there is not a form sent back with them when they return from dialysis. The resident stated staff did not assess their dialysis port before or after dialysis. They stated the only people who have anything to do with their dialysis port is the dialysis center. They stated they were not assessed prior to or after dialysis treatments. On 03/25/24 at 1:43 p.m., the DON stated dialysis communication forms were sent with the resident but rarely returned. They stated the forms when returned are filed into the resident's chart. On 03/26/24 at 8:43 a.m., the DON was informed there were no communication forms in the resident's chart. They stated they were unable to recall if they had ever received a communication form from the facility. The DON stated the assessment completed on the resident related to dialysis was a weight before and after the treatment. The DON stated if there are issues that needed to be communicated with the dialysis center there would be a phone call. They stated because the resident had lived in the facility before the staff was familiar with the resident and did not require an order to know when the resident was to go to dialysis. They stated there was no documentation in the chart for an order to monitor or send the resident but the resident probably needed a treatment order related to their dialysis and assessment. When asked where the order for dialysis was in the resident's chart the DON stated they had never had an order for dialysis before.

Based on record review and interview the facility failed to ensure medications were administered as ordered for one (#13) of five sampled residents reviewed for unnecessary medications. The DON identified 53 residents resided in the facility. Findings: Res #13 had diagnoses which included heart failure, hypertension, and diabetes. A physician order, dated 02/09/24, documented to administer insulin aspart according to sliding scale before meals and at bedtime. A physician order, dated 02/09/24, documented to administer metoprolol tartrate 25 mg two times per day for hypertension. The order documented to hold the medication for a heart rate less than 65. A MAR for February 2024 documented the metoprolol was administered when the resident's heart rate was less than 65 five times. A MAR for February 2024 documented the 11:00 a.m. Insulin Aspart was administered greater than one hour after the scheduled time nine times. A physician order, dated 02/09/24, documented to administer Insulin Detemir 5 units twice per day. A MAR for February 2024 documented the 7:00 a.m. insulin detemir was administered greater than one hour after the scheduled time 12 times and the 9:00 p.m. insulin detemir was administered greater then one hour after the scheduled time three times. A MAR for March 2024 documented the insulin detemir was administered greater than one hour after the 7:00 a.m. scheduled time 5 times and the 7:00 p.m. scheduled time 4 times. A physician order, dated 03/13/24 documented to administer Lantus Subcutaneous Solution 5 units subcutaneously two times A MAR for March 2024 documented the Lantus was administered greater than one hour after the 7:00 a.m. scheduled time one time. A physician order, dated 03/13/24, documented to administer Humalog according to sliding scale before meals and at bedtime. A MAR for March 2024 documented the Humalog insulin was administered greater than one hour after the 11:00 a.m. scheduled time one time. On 03/26/24 at 8:47 a.m., the DON stated medications should be administered no later than one hour before or one hour after the scheduled time. On 03/26/24 at 8:56 a.m., CMA #1 stated the blood pressure medications should have been held if the heart rate parameter was not met. They stated the nurse should have been notified and the actions taken documented in the resident's chart.

Based on observation and interview, the facility failed to ensure the kitchen was kept clean and maintained in good repair. The DM identified 51 residents received services from the kitchen. Two residents received nutrition and hydration solely through a feeding tube. Findings: On 03/24/24 at 9:05 a.m., a tour of the kitchen was conducted. The following observations were made. a. there was lint on the ceiling vents and the ceiling around the vents, b. there was an accumulation of lint on the white floor fan, c. there were wall tiles missing behind the stove, d. there were holes and material was peeling off the wall below the three compartment sink, e. a baseboard tile was pulling away from wall near the back door, f. there were gaps and daylight was visible on the side and under the back door, g. baseboards were missing on the walls in the dish machine area, h. there was an accumulation of white residue on and in the dish machine, i. there was black residue inside of the ice machine, j. there was black residue on the floor under equipment, k. there was a box of foam cups stored on the floor in the dry storage area, l. there were multiple boxes of supplements and juice stored on the floor in the dry storage, and m. the baseboard was missing off the wall in the employee storage area. On 03/26/24 at 9:13 a.m., the DM was asked how staff ensured the kitchen was kept clean and maintained in good repair. They stated they cleaned daily and there was a maintenance log where they recorded maintenance concerns. They were asked what was the protocol for the storage of food and single service items. They stated they should be stored off of the floor. They were shown and made aware of the above observations

Based on observation, record review, and interview, the facility failed to ensure infection control measures were followed during fingerstick glucose monitoring for nine (#7, 13, 20, 24, 29, 33, 42, 52, and #207) of nine residents who were observed during fingerstick glucose monitoring. Corporate nurse consultant #1 identified 12 residents who received fingerstick glucose monitoring. Findings: An Obtaining a Fingerstick Glucose Level policy, dated October 2010, read in parts, .Wear clean gloves .Wash the selected fingertip, especially the side of the finger, with warm water and soap .clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice .Remove gloves . Wash hands . On 03/25/24 at 11:15 a.m., LPN #2 was observed performing fingerstick glucose monitoring. The following observations were made: At 11:21 a.m., LPN #2 washed hands with soap and water, donned gloves, and cleansed the top of the medication cart with a disinfectant wipe. They removed two glucometers from the medication cart and cleansed each glucometer with disinfectant wipes. LPN #2 placed both glucometers on top of a disinfectant wipe that had been placed on the top of the medication cart. LPN #2 doffed gloves but did not perform hand hygiene. At 11:27 a.m., LPN #2 donned gloves and performed a FSBS on Res #20. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #1. Glucometer #1 was placed on the same disinfectant wipe on the top of the medication cart. At 11:31 a.m., LPN #2 donned gloves and performed a FSBS on Res #42. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #2. Glucometer #2 was placed on the same disinfectant wipe on the top of the medication cart. At 11:36 a.m., LPN #2 donned gloves and performed a FSBS on Res #52. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #1. Glucometer #1 was placed on the same disinfectant wipe on the top of the medication cart. At 11:43 a.m., LPN #2 donned gloves and performed a FSBS on Res #24. LPN #2 did not cleanse Res #24's fingertip prior to piercing the skin with a lancet. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #1. Glucometer #1 was placed on the same disinfectant wipe on the top of the medication cart. LPN #2 walked into an employee office and drank out of a personal drink cup before returning to the medication cart without performing hand hygiene. At 11:45 a.m., LPN #2 donned gloves and performed a FSBS on Res #33. LPN #2 did not cleanse Res #33's fingertip prior to piercing the skin with a lancet. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #1. Glucometer #1 was placed on the same disinfectant wipe on the top of the medication cart. At 11:48 a.m., LPN #2 donned gloves and performed a FSBS on Res #7. LPN #2 did not cleanse Res #7's fingertip prior to piercing the skin with a lancet. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #2. Glucometer #2 was placed on the same disinfectant wipe on the top of the medication cart. At 11:52 a.m., LPN #2 donned gloves and performed a FSBS on Res #13. LPN #2 did not cleanse Res #13's fingertip prior to piercing the skin with a lancet. They doffed gloves post procedure but did not perform hand hygiene or disinfect glucometer #2. Glucometer #2 was placed on the same disinfectant wipe on the top of the medication cart. At 12:00 p.m., LPN #2 donned gloves and performed a FSBS on Res #207. LPN #2 did not cleanse Res #207's fingertip prior to piercing the skin with a lancet. LPN #2 cleansed glucometer #1 post procedure with a disinfectant wipe for approximately 5 seconds and then placed glucometer #1 back into the top drawer of the medication cart. They doffed gloves but did not perform hand hygiene. At 12:05 p.m., LPN #2 donned gloves and performed a FSBS on Res #29. LPN #2 did not cleanse Res #29's fingertip prior to piercing the skin with a lancet. LPN #2 cleansed glucometer #2 post procedure with a disinfectant wipe for approximately 5 seconds and then placed glucometer #2 back into the top drawer of the medication cart. They doffed gloves post procedure but did not perform hand hygiene. At 12:08 p.m. corporate nurse consultant #1 approached the medication cart and stated, I am going to stop this observation, I would like to speak to this nurse in private. At 12:15 p.m., corporate nurse consultant #1 stated they had ended the observation due to having observed LPN #2's lack of infection control measures. They stated LPN #2 should have performed hand hygiene before and after wearing gloves. Corporate nurse consultant #1 stated the glucometers should have been cleansed after each use. At 12:20 p.m., LPN #2 stated hand hygiene should be performed before and after every fingerstick blood sugar. They stated having changed gloves but not performed any hand hygiene during the observation. LPN #2 stated they were taught not to cleanse the fingertip with an alcohol pad prior to obtaining a blood sample because the alcohol residue could alter the results, but they probably should have cleansed the fingertips with something to ensure they were disinfected. LPN #2 stated they should have cleansed the glucometers thoroughly between residents and alternated the glucometers while each dried to ensure proper disinfection procedures. At 12:45 p.m., the DON was made aware of the observations. The DON stated LPN #2 should have performed hand hygiene prior to and after each procedure. They stated the glucometers should have been cleansed and allowed to dry in between residents. The DON stated the use of two glucometers was intended to allow time for proper disinfection and drying time between residents. They stated the residents' fingertips should have been cleansed prior to piercing the skin. The DON stated LPN #2 did not ensure proper infection control measures during fingerstick glucose monitoring.

Based on record review and interview, the facility failed to educate, offer, and screen residents for eligibility to receive the pneumococcal vaccination for one (#34) and failed to educate, offer, and screen residents for eligibility to receive the influenza vaccination for one (#37) of five sampled residents reviewed for immunizations. The DON identified 53 residents who resided in the facility. Findings: A Pneumococcal Vaccine policy, revised April 2012, read in parts, .Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission in not conducted prior to admission . Before receiving the Pneumovax, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine .Provision of such education shall be documented in the resident's medical record .Pneumococcal vaccinations will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician approved pneumococcal vaccination protocol .If refused, appropriate entries will be documented in each resident's medical record indicating the date of refusal of the pneumococcal vaccination . An Influenza Vaccine policy, revised April 2012, read in parts, .Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccination is medically contraindicated or the resident has already been immunized .Prior to the vaccination, the resident (or resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine .Provision of such education shall be documented in the resident's medical record .A resident's refusal of the vaccine shall be documented in the resident's medical record . There was no documentation in the medical record indicating Res #34 was screened for eligibility to receive the pneumococcal vaccination, education regarding risks, benefits, side effects, and the consent and/or declination of the vaccination. There was no documentation in the medical record indicating Res #37 was screened for eligibility to receive the influenza vaccination, education regarding risks, benefits, side effects, and the consent and/or declination of the vaccination. On 03/27/24 at 12:11 p.m., the DON stated no documentation could be located indicating Res #34 and Res #37 had been offered, screened, provided education, consented, or declined the vaccinations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure a specific condition and diagnosis was documented, based on a comprehensive assessment/evaluation, for the use of a psychotropic medication for one (#16) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented eight residents who received an antipsychotic medication. A facility policy, Psychotropic Medication Use, dated July 2022, documented in parts, .Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record .Consideration of the use of any psychotropic medication is based on comprehensive review of the resident .This includes evaluation of the resident's signs and symptoms in order to identify underlying causes . Resident #16 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and dementia. An MDS admission Assessment, dated 07/28/22, documented the resident was severely impaired with cognition. The assessment documented the resident received antipsychotic medications seven of seven days previous and antidepressants seven of seven days previous. The assessment documented no behaviors. A monthly Medication Regimen Review, dated 08/05/22, documented a note from the pharmacist to the physician, which read in parts, .resident is currently receiving olanzapine {Zyprexa, an antipsychotic drug} .2.5 mg PO at HS for depression .olanzapine is only indicated for depressive episodes associated w/Bipolar disorder in combination with Fluoxetine . Resident does not have a dx of Bipolar disorder .Could a D/C of this medication be attempted or, if antipsychotic treatment of depression is indicated, could her olanzapine be changed to an antipsychotic with an indication for depression as adjunct therapy (i.e. Abilify 5 mg PO daily or Seroquel 50 mg PO q evening)? Please advise . The physician response documented, Please add dx of Bipolar D.O. A Progress Note, dated 10/19/22, documented an incident in which resident #16 hit another resident. The note documented resident #16 was antagonized and became agitated by the other resident, resulting in the behaviors. The note documented resident #16 was sent to a geri-psych facility for an inpatient stay. A progress note, dated 10/28/22 at 11:47 a.m., documented facility staff had talked with resident #16's physician regarding the resident's increased agitation at night. The note documented an order was received for Ativan (an antianxiety medication) 0.5 mg at night. A social service progress note, dated 12/29/22, documented resident #16 returned to the facility from a local hospital. The note documented facility staff had reported the resident was combative during transport. An MDS Quarterly Assessment, dated 01/28/23, documented the resident was severely impaired with cognition. The assessment documented the resident received antipsychotic medications seven of seven days and antidepressants seven of seven days. The assessment documented no behaviors. A Care Plan, updated 02/03/23, documented resident #16 had exhibited behaviors of being verbally and/or physically aggressive with other residents. The care plan documented incidents involving other residents had occurred on 10/19/22, 10/29/22, 12/18/22, 12/21/22, and 01/09/23. Recommended interventions included redirection, checking labs, checking for UTI, medications as ordered, and cognitive assessments. The care plan documented a behavior of wandering. The care plan documented the resident received routine antidepressant medications, as well as antipsychotic medications related to Alzheimer's dementia and Bipolar disorder. On 02/08/23 at 1:14 p.m., resident #16's physician, as well as the facility Administrator and DON, were interviewed. The physician reported the facility called him every time there was an incident with the resident. The physician stated he had tried to avoid using excessive medications for this resident to avoid over-sedation. The physician and the facility Administrator discussed possible placement in a memory care unit for this resident and stated they would speak with the resident's family to consider it further. The DON reported the resident was currently doing much better now but stated the resident had appeared heavily medicated when she returned from the last geri-psych inpatient stay. On 02/09/23 at 8:25 a.m., the DON was interviewed regarding resident #16's diagnosis of Bipolar disorder. The DON reviewed the Medication Regimen Review from 08/05/22. The DON was asked if the resident had been assessed or received a psychiatric evaluation to determine the diagnosis of Bipolar disorder. The DON reported the resident had been sent out for a geri-psych stay but wasn't sure of the time-frame. The DON reviewed the clinical record and reported the resident was not given the diagnosis of Bipolar disorder related to the geri-psych stay. After review of the clinical record, the DON stated the physician had given the resident the diagnosis of Bipolar disorder for the continued use of olanzapine.