**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure an accurate assessment for three of 31 residents reviewed in the sample (Resident (R) 12, R7, and R93). R12's assessment inaccurately documented received insulin, R7's assessment inaccurately documented he did not have a diagnosis of major mental illness defined by the Preadmission Screening and Resident Review (PASARR) program, and R93's assessment inaccurately documented she did not receive routine antipsychotic medication. These failures created a potential for lack of identification of current problems and resident needs, leading to an incomplete or ineffective plan of care. Findings include: Review of the facility's undated policy titled, Conducting an Accurate Resident Assessment revealed, Accuracy of Assessment means that the appropriate qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument . The facility will ensure that all participants in the assessment process have the requisite knowledge to complete an accurate assessment . Accurate assessments addressing each resident's status, needs, strengths, and areas of decline must be conducted by qualified staff that are knowledgeable about the resident and correctly documented in the medical record . The appropriate, qualified health professional correctly documents the resident's medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. 1. Review of R12's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed he was admitted to the facility on [DATE] with diagnoses including diabetes. Review of R12's Significant Change of Status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/25/25 and located under the MDS tab of the EMR, revealed he had a diagnosis of diabetes. The MDS documented he received one insulin injection in the lookback period. Review of R12's January 2025 Medication Administration Record (MAR), located under the Orders tab of the EMR, revealed a physician's order, dated 11/28/24, for a Trulicity injection (dulaglutide, a non-insulin medication used for the treatment of diabetes that mimics the effects of GLP-1, a naturally occurring hormone that stimulates insulin secretion) given one time per week. The MAR documented he received the medication on 01/23/25. Review of R12's Orders tab of the EMR for January 2025 and further review of the January 2025 MAR revealed there were no orders for, or administration of, insulin documented on the MAR. During an interview on 04/04/25 at 11:11 AM, the Director of MDS (DMDS) stated R12 was not taking insulin during the lookback period; he was only receiving Trulicity, which is not considered an insulin. The DMDS stated the assessment should be modified to reflect no insulin use. 2. Review of R7's admission Record, located in the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses including schizophrenia. Review of R7's PASARR Level II South Carolina Mental Health Authority Determination, dated 01/05/22 and located under the Miscellaneous tab of the EMR, revealed he had a serious mental illness as defined by PASARR regulations and required psychiatric medication management. Review of R7's Annual MDS, with an ARD of 11/20/24 and located under the MDS tab of the EMR, revealed the question, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was answered, No. During an interview on 04/04/25 at 11:14 AM, the DMDS stated R7 did have a level II serious mental illness diagnosis, and the question should have been answered, Yes. 3. Review of R93's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including schizophrenia, Alzheimer's disease, major depression, and schizoaffective disorder. Review of R93's Quarterly MDS, with an ARD of 03/11/25 and located under the MDS tab of the EMR, revealed she received antipsychotic medication in the lookback period. However, the follow-up question related to antipsychotic medication use documented no antipsychotics were used; thus, subsequent questions regarding an attempted gradual dose reduction were not completed. Review of R7's Orders tab of the EMR revealed an active physician's order, dated 02/14/25, for quetiapine fumarate (an antipsychotic medication), 12.5 milligrams twice daily for a diagnosis of major depression with psychotic symptoms. Review of R7's March 2025 MAR, located under the Orders tab of the EMR, revealed she received the antipsychotic medication routinely twice daily as ordered. During an interview on 04/04/25 at 11:15 AM, the DMDS stated the follow-up questions regarding routine antipsychotic use and gradual dose reductions should have been completed and the assessment should be modified for accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to administer oxygen therapy per physician's orders for one (Resident (R) 49) of two residents reviewed for respiratory care out of a total sample of 31 residents. This had the potential for the resident to experience respiratory distress. Findings include: Review of the facility's policy titled, Oxygen Concentrator(undated) revealed, Oxygen should be administered only under orders of the attending physician. Per the policy the first step in Care of the Resident revealed to Obtain physician's orders for the rate of flow and route of administration of oxygen. Review of the Admission record located in the electronic medical record (EMR) under the Diagnosis tab revealed R49 was originally admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypercapnia, and chronic respiratory failure. Review of R49's Orders located in the EMR under the Orders tab revealed an order, dated 08/16/23, for oxygen delivered via nose cannula, at 2 liters per minute (lpm). Review of the R49's Care Plan located in the EMR under the Care Plan tab revealed the resident has the potential for respiratory distress, initiated 12/12/22, with a goal to be free from signs and symptoms of respiratory distress using interventions that included providing oxygen and related interventions as needed or ordered. Review of R49's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/26/25 and located in the EMR under the MDS tab revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating the resident was cognitively intact. During an observation and interview on 04/02/25 at 10:09AM, R49 could be heard yelling at the nursing staff that she could not breathe. After Registered Nurse (RN) 1 left the resident's room the resident said she felt she was not getting any oxygen from the concentrator, but that she was okay, and the staff member was going to be handling it. Observation at the time revealed the resident's oxygen was set at 4 lpm. The resident was asked if she knew what her concentrator should be set to, and she stated that she did not. During an observation and interview on 04/03/25 at 10:42AM, R49's concentrator was running and was set at 3.5 lpm. Registered Nurse (RN)1 confirmed R49's oxygen was set at 3.5 lpm. RN1 stated that the concentrator was just replaced, and she thought it was likely placed on the wrong setting. She added that the licensed nursing staff are responsible for ensuring the settings are per the physicians' order and cannot be adjusted without orders from the resident's physician. The RN then adjusted the resident's oxygen to the correct order.

Based on observation, staff interview, record review, and facility policy, the facility failed to ensure a medication error rate of less than 5 percent (%). There were four errors observed out of 38 opportunities for three residents (Residents (R)78, R153, and R86) out of a total sample of 31 residents resulting in an error rate of 10.53%. These failures had the potential to cause adverse drug reactions and the residents needs being met. Findings include: Review of the facility's undated policy titled, Medication Administration, revealed Medications are administered . as ordered by the physician and in accordance with professional standards of practice. Ensure that the six rights of medication administration are followed: right resident, right drug, right dosage, right route, right time, right documentation. 1.Review of R78's Administration Record, dated April 2025, located under the Orders tab of the electronic medical record (EMR), revealed a physician's Order dated 01/31/25 for acetaminophen extra strength tablet 500 milligrams (mg), give 2 tablets by mouth two times a day for pain. The medication was scheduled to be administered at 0800 [8:00 AM] hours and 1700 [5:00 PM] hours daily. During an observation on 04/03/25 at 9:15 AM, Licensed Practical Nurse (LPN)2 LPN2 administered two 500 mg tablets of acetaminophen to the resident. 2.Review of R153's Administration Record, dated April 2025, located under the Orders tab of the EMR, revealed a physician's order dated 03/24/25 for Aspercreme original external cream 10% (trolamine salicylate), apply to neck and left (L) hand topically two times a day for pain. The medication was scheduled to be administered at 0800 [8:00 AM] hours and 2000 [8:00 PM] hours daily. During an observation on 04/03/25 at 9:37 AM, LPN2 entered R153's room and applied the cream to R153's left hand. The cream was not applied to the residents neck per the order. 3.Review of R86's Administration Record, dated April 2025, located under the Orders tab of the EMR, revealed a physician's orders dated 04/01/25 for Ofev oral capsule 150 mg (nintedanib esylate), give one (1) capsule by mouth two time a day related to pulmonary fibrosis. The medication was scheduled to be administered at 0800 [8:00 AM] hours and 1700 [5:00 PM] hours, and an order dated 04/01/25 for fluticasone propionate suspension 50 micrograms (mcg)/actuation (act), one spray in each nostril one time a day related to allergic rhinitis. The medication was scheduled to be administered every morning. During an observation on 04/03/25 at 9:49 AM, LPN2 administered two actuations (sprays) to each nostril of fluticasone nasal spray and one 150mg-tablet of Ofev to R86. During an interview on 04/03/25 at 10:23 AM, LPN2 stated scheduled medications should be administered within one hour before or one hour after the scheduled time. The LPN confirmed the above medications were administered late, that she administered two nasal sprays in each of the residents nostrils when the order said one spray in each nostril, and confirmed the medicated cream was not applied to the residents neck per the order. During an interview on 04/04/25 at 10:55 AM, the Director of Nursing (DON) stated Medications are expected to be administered within one hour before or one hour after the scheduled time.

Based on observations, interviews and review of the facility policy titled, Dignity, the facility failed to promote resident rights and to treat each resident with respect and dignity as evidenced by staff not knocking on resident room doors during the lunch meal service for 2 of 2 observations of the lunch meal service. The findings include: An observation on 11/30/21 at 11:45 AM of the lunch service on the [NAME] Hall revealed staff not knocking on resident room doors before entering with the meal trays. An additional observation on 12/1/21 at 11:40 AM revealed staff entering resident rooms with meal trays without knocking on their doors and awaiting for permission to enter. Interviews on 12/1/21 at 11:55 AM with Certified Nursing Assistant #3 and #4 stated they should be knocking on the doors before entering and confirmed that they had not knocked and waited for permission to enter. Review on 12/2/21 at 9:45 AM of the facility policy titled, Dignity, states, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity. Compliance Guidelines, under number 4. states, Respect resident's living space and personal possessions. Number 5. states, Maintain resident privacy.

Based on observation, interview and review of the facility policy titled Dressing Change, (Clean Technique), the facility failed to ensure a pressure ulcer for Resident (R) 94 was cleaned using a technique to prohibit infection or the spread of infection during wound care for 1 of 3 residents reviewed for Pressure Ulcers. The findings include: The facility admitted R94 with diagnoses including, but not limited to, Stage 4 Pressure Ulcer of the Sacrum, a Pressure Ulcer of the Right Ankle and Methicillin Resistant Staph Aureus, (MRSA). During an observation on 12/1/21 at 9:25 AM of wound care for R94 was observed as follows: Licensed Practical Nurse (LPN)2 applied his gloves and opened the 4x4s, sprayed the wound cleanser on the 4x4s, wiped inside out x1, on the second swipe, he sprayed the wound cleanser and wiped down x2 using the same gauze with the same wound cleanser. He cleaned the over the bed table and removed his gloves but did not remove the bagged trash from the resident's room. During an interview on 12/2/21 at 10:45 AM with LPN2, he stated he was aware that he had wiped down the wound 2 times using the same soaked gauze. He did not discard the gauze after one use. Review on 12/2/21 at 12:15 PM of the facility policy titled, Dressing Change (Clean Technique), number 15 states, Clean the wound according to order. Clean from center outward. Linear wound may be cleansed from top to bottom.

Based on observation, record reviews, staff interview, manufacturer's guidelines for medication administration, and review of the facility's competency checklist for Insulin Injection the facility failed to ensure that it was free of significant medication errors based on 1 of 34 medication pass observations. Findings include: On 11/29/21 at approximately 8:43 PM, Licensed Practical Nurse (LPN) 1 administered Lantus Insulin 38 units using a Lantus Solostar Pen to Resident (R) 54 on the right side of her belly after stating to the Surveyor that no air shot is required. On 11/29/21 at approximately 8:45 PM, review of the Lantus Solostar Pen by Sanofi Aventis package insert states Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by ensuring that the pen and needle work properly and removing air bubbles. A. Select a dose of 2 units by turning the dosage selector B. Take off the outer needle cap and keep it to remove the used needle after the injection. Take off the inner needle cap and discard it. C. Hold the pen with the needle pointing upwards D. Tap the insulin reservoir so that any air bubbles rise up towards the needle. E. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before insulin is seen. The facility's Competency Checklist for Insulin Injection states under Steps of Procedure 5. FOR PEN: Twist open and remove outer cover from the safety pen needle. 6. Screw the pen safety needle onto the insulin pen. 7. Dial 2 units by turning the dose selector clockwise pointing the needle up, push the plunger, and watch to see that at least one drop of insulin appears on the top of the needle. If not, repeat until at least one drop appears. On 11/29/21 at approximately 8:49 PM, LPN1, after reviewing the manufacturer's guidelines, acknowledged that a safety test had not been performed prior to administering the dose of insulin to R54.

Based on record reviews, interview and review of the facility policy titled, Pneumococcal Vaccine Program, the facility failed to ensure the physician was consulted for the receipt of the Pneumonia Vaccine for Resident (R)5 and further failed to ensure R29 was offered the Pneumonia Vaccine PPSV 23 for 2 of 5 residents reviewed for the Influenza and Pneumococcal vaccines. The findings include: The facility admitted R5 with diagnoses including, but not limited to, Cerebrovascular Accident, Vascular Dementia, Neuropathy and Malaise. Review on 12/2/21 at 12:45 PM of the Immunizations for R5 revealed a signed consent by R5's Responsible Party on 5/14/21, for R5 to receive the Pneumococcal Vaccine. The form contained a hand written note that stated, will check with doctor. No documentation could be found in the medical record for R5 to ensure the issue was followed up on with the attending physician. To date, R5 has not received the Pneumococcal Vaccine. The facility admitted R29 with diagnoses including but not limited to, Major Depressive Disorder and Anxiety Disorder. R29 has a BIMS score of 15/15 which indicates she is able to make her own health care decisions. Review on 12/2/21 at 12:45 PM of the immunization documentation for R29 indicated that R29 was not offered the PPSV23. During an interview on 12/2/21 at 1:10 PM with Licensed Practical Nurse (LPN) 2, the facility's immunization nurse, confirmed the findings and stated he did not know why the physician was not contacted concerning the Pneumococcal Vaccines for this resident. LPN2 also did not know why R29 was not offered the PPSV23 (the second Pneumonia vaccine). Review on 12/2/21 at 1:30 PM of the facility policy titled, Pneumococcal Vaccine Program, states, It is the policy of this facility that residents will be offered immunization against pneumococcal disease. Number 10 states, If patients do not know their vaccination history for pneumococcal vaccine should be given both vaccines according to the CDC recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of five sampled resident (Residents (R) 82, 85, 97 and 114) had a Level II Pre-admission Screening and Resident Review (PASARR) evaluations completed despite being diagnosed with a serious mental disorder or intellectual disability. This failure placed the residents at risk for unmet care needs and at risk for not receiving appropriate mental health support/services needed. Findings Include: 1. Review of R82's electronic medical record (EMR), Face Sheet stated, R82 was admitted on [DATE] with diagnoses of but not limited to schizoaffective disorder, bipolar type, and other schizoaffective disorders. Review of R82's EMR, admission Minimum Data Set (MDS) (an assessment used to determine plan of care for a resident) dated 4/22/21, documented in Section C - Cognitive Patterns R82 scored a 13 on the Brief Instrument for Mental Status (BIMS) assessment (an assessment to determine level of cognition). In Section D - Mood documented R82 had symptoms of feeling down, depressed, or hopeless. In Section E - Behaviors, no behaviors were documented for R82. In Section G - Functional Status, R82 was documented to need extensive to total dependence on staff assistance for activities of daily living (ADLs). Review of the R82's PASARR level 1 dated 04/06/21, identified the resident as having bipolar disorder under section .II. Screening for Mental Illness Indicators . Under section IV, Recommendation of Reviewer, No further evaluation recommended was checked, with the reason given in the comments being that the resident's Bipolar [is] controlled on meds. In an interview with the Social Worker (SW) on 12/01/21 at 2:20 PM, when inquired about the lack of a PASSAR Level II, the SW indicated that the Level II was not necessary because the resident's behavior was under control with medications and had not been hospitalized for reasons pertaining to the resident's mental diagnosis. The facility admitted R85 with diagnoses including, but not limited to, Bipolar Disorder, Schizoaffective Disorder and Major Depressive Disorder. Review of the Preadmission Screening and Resident Review (PASARR) Level 1 for R85 revealed a diagnosis of Bipolar Disorder and Major Depressive Disorder. There was no documentation of behaviors, but he was started on 100 milligrams of Seroquel, an antipsychotic medication and due to a episode of anxiety, the Seroquel was increased to 200 milligrams . The facility did not ensure a PASARR Level II evaluation for R85 was completed due to a mental disorder or related condition to ensure he receives the care and services appropriate for his needs. The facility admitted R97 with diagnoses including, but not limited to, Post Traumatic Stress Disorder (PTSD) and Depression. Review of the Preadmission Screening and Resident Review (PASARR) for R97 revealed a diagnosis for PTSD,however, the facility did not ensure a PASARR Level 11 was completed. R97 has a mental illness that requires a PASARR Level 11 to ensure he receives care and services appropriate for his needs. During an interview on 12/2/21 at approximately 1:15 PM with the SW, she stated she had been at the facility about 60 days now and was not aware the previous SW was not reviewing for Level 2 PASARRs being completed. She confirmed after reviewing the 4 residents reviewed during the survey, that the residents should have had a level 2 completed due to their Mental Health Diagnosis or Disability Diagnosis. She confirmed if a resident with a mental health diagnosis was not screened properly, it could result in that resident not getting the mental health services they need. She confirmed the facility's policy and procedure was not followed. Review on 12/2/21 at approximately 1:30 PM of the facility policy titled, PASARR Policy, states under Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Number 5 (a) states, The facility must screen the individual using the State's Level 1 screening process and refer any resident who has or may have Mental Disabilities or Intellectual Disabilities or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. Number 9 states, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred to the state mental health or intellectual disability authority for a Level II resident review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Centers for Medicare and Medicaid S&Q Memo Ref 13-35-NH dated May 24, 2013, revealed: . The problematic use of medications, such as antipsychotics, is part of a larger, growing concern. This concern is that nursing homes and other settings (i.e., hospitals, ambulatory care) may use medications as a quick fix for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized, person-centered interventions . When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective. In addition, they commonly cause complications such as movement disorders, falls, hip fractures, cerebrovascular adverse events (cerebrovascular accidents and transient ischemic events) and increased risk of death . Review of the manufacture's guidelines for the use of the medication Seroquel last updated 10/20 revealed, .Approved Uses Seroquel is a once-daily tablet approved in adults for major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; bipolar disorder; acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; long-term treatment of bipolar disorder with lithium or divalproex; and schizophrenia .Elderly patients with dementia-related psychosis (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death, compared to placebo (sugar pill). Seroquel is not approved for treating these patients . A review of R19's Face Sheet in the electronic medical record (EMR) revealed R19 was admitted on [DATE] with diagnoses of vascular dementia with behavioral disturbance, cerebral infarction, and unspecified dementia without behavioral disturbance. Review of R19's EMR admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/25/21, revealed R19 had a Brief Interview for Mental Status (BIMS) score of 09 out of 15, which indicated R53 was cognitively impaired. Further review of the MDS assessment revealed R19's behaviors were limited to occasional wandering. Further review of the MDS assessment revealed R19 received routine antipsychotics seven (7) days of the ARD period. Review of R19's EMR quarterly MDS assessment, with an ARD of 08/25/21, revealed R19 had a BIMS score of 06 out of 15, which indicated R19 was severely cognitively impaired. Further review of the MDS assessment revealed R19 displayed verbal behaviors, episodes of wandering, and rejection of care. Further review of the MDS assessment revealed R19 received antipsychotics routinely for seven (7) days of the ARD period. Review of R19's Physician Orders dated from 02/19/21 through 12/02/21, located on the EMR under the Orders tab revealed R19 had been prescribed Seroquel (an antipsychotic medication) daily, starting 02/19/21 with 50mg (milligrams) at bedtime. This dosage was reduced to 25mg at bedtime on 10/18/21, and then raised to 50mg on 11/18/21. Review of the pharmacy Consultation Report for R19, dated 05/07/21, revealed that the consultant pharmacist recommended a gradual dose reduction (GDR) for Seroquel from 50mg to 25mg with a goal of eventually discontinuing the order. A written memo at the bottom of the report notes that the request was Verbally declined per MD (Medical Doctor) r/t (related to) unable to tolerate GDR. Behaviors stable with current order. There was no medical rationale documented in R19's EMR to support the continued use and increase in the antipsychotic medication Seroquel. Review of R19's pharmacy Consultation Report for GDR recommendations dated 10/09/21, revealed documentation that the pharmacy recommended the reduction of Seroquel to 25mg with the goal of eventual discontinuation. The physician accepted the recommendation, and the order was reduced to 25mg on 10/18/21, however, then raised to 50mg on 11/18/21 with no documented medical rationale to support the increase in the antipsychotic medication Seroquel. Review of EMR Progress Notes for the months of October and November revealed that R19 was monitored daily for behaviors, with no documented behaviors noted related to the use of the medication Seroquel. Review of EMR Progress Notes dated 11/15/21, 11/16/21 and 11/17/21 revealed the resident was agitated and demonstrated verbal behaviors regarding noises from other residents and noises the resident could hear from the hallway. The notes on 11/17/21 noted that the resident was easily redirected. There were no notes on 11/15/21 and 11/16/21 to show the staff attempted non-pharmacological interventions to redirect R19's behavior prior to the increase of the medication Seroquel as there were on 11/17/21. Review of the EMR Progress Notes dated 11/18/21 revealed that R19's order for Seroquel had been increased to 50mg with no documented medical rationale. R19 was observed on 12/02/21 at 10:53 AM resting calmly in bed. In an interview with LPN3 on 12/02/21 at 11:00 AM, stated that R19 sometimes blurted out obscenities when agitated, but noticed that R19 had been much calmer since the change in R19's medication. When asked about non-pharmacological interventions used with R19 for exhibited behaviors, LPN3 stated R19 was easily redirected by offering a snack. The facility admitted R85 on 4/20/21 with diagnoses including, but not limited to, Bipolar Disorder, Schizoaffective Disorder and Major Depressive Disorder. Review on 12/2/21 at 1:28 PM of the Medication Administration History for R85 indicated that R85 was admitted on Seroquel 100 milligrams, an antipsychotic medication. He was increased to 200 milligrams of Seroquel on 7/19/21, due to an episode of anxiety. Seroquel is not an antianxiety medication. The nurses notes did include documentation of the episode of anxiety. Review on 12/2/21 at 1:45 PM of the Behavior Monitoring Sheets for R85 did not include any episodes of anxiety or any behaviors for this resident. In the medical record, behavior monitoring sheets dated 11/1/21-11/30/21 did not indicate behaviors were present. During an interview on 12/2/21 at 1:50 PM with the Registered Nurse Consultant, she confirmed that November was the only month behaviors were monitored and that there were none. The consultant stated, there are no behavior monitoring sheets in the medical record for R85. No documentation of a diagnosis could be found in the medical record for R85 to ensure the medication Seroquel was a necessary medication for this resident. Based on observation, record review, staff interviews, manufacturer's guidelines for medication use, and review of the facility's policy and procedures, the facility failed to ensure that four of six residents (Resident (R) R113, R109, R85, and R19) were free from unnecessary psychotropic medications. Findings include: Review of the facility's policy entitled The Use of Psychotropic Drug Policy (not dated) revealed Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s).Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety and hypnotics.2. The indications for initiating, withdrawing, or withholding medications(s), as well as the use on non-pharmacological approaches, will be determined by: a. Assessing the resident's underlying condition, current signs, symptoms, expressions, and preferences and goals for treatment. b. Identification of underlying causes (when possible).3. The attending physician will assume leadership in medication management by developing, monitoring and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team. 4. The indications for use of any psychotropic drug will be documented in the medical record. a. Pre-admission screening and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility. b. For psychotropic drugs that are initiated after admission to the facility, documentation shall include the specific condition as diagnosed by the physician. i. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. ii. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation 10. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's monthly medication regimen review, c. During MDS review (quarterly, annually, significant change), and d. In accordance with the nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. Review of the Seroquel (quetipine fumarate) (an antipsychotic) by AstraZeneca Pharmaceutical package insert guidelines under FULL PRESCRIBING INFORMATION (last revised October 2013) revealed that the drug has a Black Box Warning (The United States Food and Drug Administration's most serious warning about drugs or medical devices. A drug or device with a black box warning has side effects that may cause serious injury or death.) which states: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS. AstraZeneca Pharmaceuticals specified INDICATIONS AND USAGE states: 1.1 Seroquel is indicated for the treatment of schizophrenia and 1.2 Seroquel is indicated as monotherapy for the acute treatment of manic episodes associated with bipolar I disorder, both as monotherapy and as an adjunct to lithium or divalproex. Review of the Depakote DR/ER (divalproex sodium delayed release/extended release) (bipolar disorder, acute manic) by AbbVie package insert Indications (last revised July 2020) revealed that the medication is indicated for the treatment of acute manic or mixed episodes associated with bipolar disorder, with or without psychotic features. On 12/1/21 at approximately 12:15 PM, a review of the medical records for R113 who was admitted to the facility from Encompass Health Rehabilitation Hospital of [NAME] on 9/27/21 with diagnoses including, but not limited to, dementia with behaviors and cellulitis of right upper limb. The Encompass Health discharge record for R113 states postoperatively had some agitation and was started on quetiapine with discharge orders for quetiapine 25 mg (milligram) daily. On 12/1/21 at approximately 12:25 PM, review of the medical record for R113 revealed that upon admission to the facility on 9/27/21, Quetiapine 25 mg daily was prescribed for dementia with behaviors and on 9/28/21 Divalproex DR/ER 125 mg bid (twice daily) was prescribed for dementia and behaviors. On 12/1/21 at approximately 1:05 PM, review of the medical record revealed that on 10/30/21 R113 was discharged to [NAME] Hospital due to worsened swelling of right hand where quetiapine was increased from 25 mg once a day to twice a day and divalproex was increased from 125 mg to 250 mg twice daily. On 12/1/21 at approximately 1:30 PM review of the medical record showed that on 11/2/21 R113 was readmitted to the facility whereby the hospital orders for quetiapine 25 mg twice daily and divalproex DR 250 mg twice daily were continued. On 12/1/21 at approximately 1:45 PM a review of the MAR (medication administration record) for R113 showed that all doses of quetiapine and divalproex had been administered as ordered from 9/27/21 to 10/30/21 and from 11/2/21 to 12/2/21 and that there was a physician's order: Monitor behaviors every shift for hitting, biting, scratching, fighting, kicking, hallucination, delusions, or continuous crying out, yelling, screaming, side effects lethargy, loss of appetite. Notify MD (physician) if side effects noted. Further review of the MAR since admission on [DATE] revealed no charted behaviors. On 12/1/21 at approximately 2:30 PM, Registered Nurse (RN) 1 was interviewed and stated R113 rarely has any behaviors other than being confused and going back and forth between his room and the nursing station. RN1 confirmed that behaviors were monitored twice daily and that there had been no behaviors documented since R113 was admitted on [DATE]. On 12/2/21 at approximately 9:40 AM, Certified Nursing Assistant (CNA) 1 stated that R113 was frequently confused, did not have any bad behaviors and was easy to redirect when necessary. On 12/2/21 at approximately 11:54 AM, the Consultant Pharmacist MRR (Medication Regimen Review) for R113 dated 11/29/21 was provided by the DON (Director of Nursing) and Nurse Consultant. The MRR included a recommendation, not yet acted upon by the physician, to attempt to taper and discontinue quetiapine fumarate 25 mg twice daily because of the Black Box Warning: It may increase the risk of death when used to treat mental related issues caused by dementia in elderly patients. Most of the deaths were linked to heart problems or infection. This medicine is not approved to treat mental related issues caused by dementia. Do you feel we could attempt to taper and discontinue medication? If you feel the benefits outweigh the risks, please document rationale below for continuing medication. On 12/2/21 at approximately 12:20 PM the DON and Nurse Consultant provided a copy of the Medical Director's verbal order dated 1/2/21 stating Resident has no behaviors, stable on current meds. Reduce to 25 mg qhs (bedtime) x 1 month an then D/C (discontinue). On 12/2/21 at approximately 10:36 AM, a review of the medical records for R109 who had been admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia with behavioral disturbances. Further review of the physician's orders since August 2021 revealed medication orders for Seroquel 25 mg twice a day dated 1/16/21 for unspecified dementia with behavioral disturbance and divalproex) Sprinkles, delayed release 125 mg x 2 (250 mg) twice a day dated 5/26/21 for unspecified dementia with behavioral disturbance. Further medical record review revealed a physician's order: Monitor behaviors every shift for hitting, biting, scratching, fighting, kicking, hallucination, delusions, or continuous crying out, yelling, screaming, side effects lethargy, loss of appetite. Notify MD (physician) if side effects noted. twice a day since 5/3/19. Review of the MAR since August, 2021 revealed no charted behaviors and that all scheduled doses for quetiapine and divalproex had been administered. On 12/2/21 at approximately 11:54 AM the Consultant Pharmacist MMR for R109 dated 11/29/21 was provided by the DON and Nurse Consultant and included a recommendation, not yet acted upon by the physician, to attempt to taper and discontinue quetiapine 25 mg (milligram) twice daily because of the Black Box Warning: It may increase the risk of death when used to treat mental elated issues caused by dementia in elderly patients. Most of the deaths were linked to heart problems or in infection. This medicine is not approved to treat mental related issues caused by dementia. On 12/2/21 at approximately 12:20 PM, the DON and Nurse Consultant provided a copy of the Medical Director's verbal order dated 12/2/21 stating Seroquel 25 mg q (every) hs should be continued for 1 month, then discontinued. On 12/2/21 at approximately 1:15 PM further medical record review for R109 revealed a psych (Psychiatry) consult ordered by the physician on 6/23/21 and a Psychiatry Follow Up Note from LifeSource, Inc. dated 11/2/21 which states Diagnoses of concern during today's encounter include: dementia. The LifeSource notes under Current Medications revealed: seroquel, Dose 25mg, Frequency: BID (twice daily) Continue seroquel as prescribed, the patient is stable at current dose and/or needs more time to see beneficial effect. Dose reduction attempted and/or reduction will cause decompensation of patient and Depakote, Dose 250 mg/1, Unit: TABLET, EXTENDED RELEASE, ORAL, Qty: 1, Frequency: BID Continue seroquel as prescribed, the patient is stable at current dose and/or needs more time to see beneficial effect. Dose reduction attempted and/or reduction will cause decompensation of patient. The LifeSource Psychiatry Follow Up Note included a recommendations made on 11/2/21 to Decrease seroquel 12.5 mg bid. There was no evidence in the medical record that this recommendation had been acted upon. On 12/2/21 at approximately 1:30 PM RN2 was interviewed and stated R109 rarely had any behaviors other than occasionally being confused. On 12/2/21 at approximately 1:40 PM CNA2 stated that R109 occasionally becomes frustrated with her roommate, but that she is easily redirected with coloring pictures from a coloring book with crayons. CNA2 stated that R109 enjoys doing this activity in the day room and with her roommate. On 12/2/21 at approximately 2:00 PM the Medical Director (MD)/Attending Physician was interviewed via telephone. The MD stated he had been with the facility for about 10 years and his training included geriatrics during his residency, but he is not a gerontologist. He stated that he is in the facility at least weekly and is on the phone with someone at the facility daily. He receives Consultant Pharmacist recommendations regularly and has a Nurse Practioner who visits the facility frequently. He makes behavioral rounds, meets with families and gets resident decision-making assessments from nursing. When asked about medication use management for residents prescribed anti-psychotics while in the facility or admitted on anti-psychotics he stated that he understands the rule about how they are to be prescribed, but it is a thin line and he cuts back when appropriate.

Based on an observation, interview and review of the facility policy titled, Lint Screen Policy, the facility failed to ensure a large amount of lint build-up was removed from above the lint baskets on the wiring and the upper three sides of 2 of 3 clothes dryers. The finding include: An observation on 12/2/21 at 1:23 PM of the laundry department revealed 2 of 3 clothes dryers with a large amount of lint build up above the lint baskets on the wiring and on the upper three sides of 2 of 3 clothes dryers. An interview on 12/2/21 at 1:24 PM with the Laundry Lead confirmed the findings. Review on 12/2/21 at 2:00 PM of the facility policy titled, Lint Screen Policy, states, Lint screens and dryer compartments will be cleaned according to CMS/State Guidelines. Number 1 states, Laundry staff will clean the lint screens after every drying cycle to prevent build-up. Number 2 states, Maintenance techs will vacuum and clean the lint screen compartment, the top compartment and back of dryers monthly to prevent build-up.