**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review and interviews, the facility failed to prevent the use of a psychotropic medication without a related diagnosis for 1 resident (Resident #32) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled Antipsychotic Medication Use dated 12/2016, showed .Antipsychotic medications may be considered for residents with dementia but only after medical, physical .psychological, emotional psychiatric, social .environmental causes of behavioral symptoms have been identified and addressed .Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .will identify .symptoms that may warrant the use of antipsychotic medications .Residents who are admitted from the community .transferred from a hospital .who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use . Resident #32 was admitted to the facility on [DATE] with diagnoses including Depressive Disorder, Anxiety Disorder, Alzheimer's Disease, Dementia, Long Term use of Anticoagulants and Cognitive Communication Deficit. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #32 had severe cognitive impairment. Further review revealed active diagnoses of .Alzheimer's .Anxiety .Depression . (a Psychotic disorder was not indicated) and the resident had received antipsychotic, antianxiety, antidepressant medications on all 7 days of the 7 day look back period. Review of the current Comprehensive Care Plan showed Resident #32 received anti-psychotics, anti-depressants, and anti-anxieties with interventions including pharmacy review of the drug regimen (by the pharmacist) for identification and drug interactions. Review of the Medication Administration Record (MAR) dated 8/2022 showed .Quetiapine Fumarate [an antipsychotic medication used to treat mental and mood disorders] 25 mg [milligrams-unit of measure] .by mouth at HS [hour of sleep] . Resident # 32 was admitted to the facility from the hospital on Quetiapine Fumarate (Seroquel). The medication was increased 2 times on 8/19/2022 and again 8/26/2022. Review of the monthly pharmacy review dated 8/17/2022 showed no recommendations and did not indicate Resident #32 was receiving Seroquel with no psychosis diagnosis. Review of the MAR dated 9/2022 showed Resident #32 continued to receive Seroquel (Quetiapine Fumarate) with an increase in dosage on 9/2/2022. The MAR for 9/2022 showed no indications for the usage of Seroquel. Review of the initial Psychiatric Evaluation dated 8/16/2022, showed Resident #32 had a history of anxiety and depression. The evaluation showed staff reported episodes of crying spells with pacing the hallways. The evaluation showed no psychotic symptoms assessed or reported. During a telephone interview on 9/8/2022 at 10:22 AM, the Pharmacist stated Resident #32 had been admitted from the hospital on the Seroquel and she completed Resident #32's medication review on 8/17/2022. The Pharmacist confirmed there was no supporting psychosis diagnosis for the use of Seroquel and had not consulted with the medical doctor regarding the prescribed medication. During an interview on 9/8/2022 at 11:22 AM, the Director of Nursing (DON) confirmed Resident #32 had received Seroquel without a diagnosis of psychosis since admission to the facility on 8/5/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the call light was kept within reach for 2 Residents (# 20 & #131) of 22 residents sampled. The findings include: Review of the facility policy, Answering Call Lights revised 6/1/16 revealed .When the resident is in the bed or confined to a chair be sure the call light is within easy reach of the resident . Medical record review revealed Resident #20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Lack of Coordination, Anxiety Disorder, Schizoaffective Disorder Bipolar Type, and Pain. Medical record review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8 indicating the resident had moderate cognitive impairment. Further review revealed the resident required extensive assistance of 1 staff member for bed mobility and transfers, assistance of 1 staff member for walking in the room, and extensive assistance of 2 staff members for toileting. Medical record review of the Care Plan dated 8/1/18 revealed .At risk for falls related to generalized weakness .Call light in reach . Observation and interview with Certified Nursing Assistant (CNA) #1 on 8/27/18 at 11:27 AM, in the resident's room, confirmed the call light was lying in the floor at the bedside. Further interview confirmed the resident was able to use the call light to ask for assist with CNA stating .sometimes he does . Observation of Resident #20 on 8/27/18 at 1:19 PM, in the resident's room, revealed the resident lying in the bed with the call light lying on the floor at the bedside. Observation of Resident #20 on 8/27/18 at 2:12 PM, in the resident's room, revealed the resident lying in the bed with the call light lying on the floor at the bedside. Observation and interview with Licensed Practical Nurse (LPN) #1 on 8/27/18 at 2:17 PM, in the resident's room, confirmed the call light was lying on the floor at the bedside. Medical record review revealed Resident #131 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Dementia with Behavior Disturbance, Dysphagia, Acute Kidney Failure and Difficulty Walking. Medical record review of the Care Plan dated 8/11/18, revealed the resident was at risk for falls related to Generalized Weakness, Dementia, Balance Issues and a History of Falls with Interventions including call bell in reach. Medical record review of an admission MDS dated [DATE], revealed the resident had a BIMS score of 4, indicating the resident had severe cognitive impairment. Continued review revealed the resident required extensive assistance of 2 for bed mobility, transfers, and toileting and required assistance of 1 staff member for walking in the room. Observation and interview with LPN #2 on 8/27/18 at 8:55 AM, in the resident's room revealed the resident lying in bed with his gown pulled up and the call bell lying on the floor at bedside. Interview with LPN #2 on 8/27/18 at 9:00 AM, outside the resident's room confirmed the residents call light was not within reach of the resident. Observation and interview with CNA #2 on 8/28/18 at 3:15 PM, in the resident's room revealed the resident lying in bed with his gown pulled up and the call light was lying on the floor at bedside. Interview with CNA #2 on 8/28/18 at 3:20 PM, outside the resident's room confirmed the call bell was not within the residents reach. Interview with the Assistant Director of Nursing (ADON) on 8/28/18 at 2:40 PM, in the ADON's office, confirmed the facility failed to ensure call light was kept within reach for Resident #20.

Based on facility policy review, observation, and interview, the facility failed to ensure expired medications were not available for resident use for 1 of 2 medication carts. The findings include: Review of the facility policy Medication Management revealed .Medications are stored, dispensed, and destroyed in a manner to ensure safety and conformance with State and Federal laws . Observation of the 2 & 4 medication cart with Licensed Practical Nurse (LPN) #1 on 8/29/18 at 8:54 AM, at the nurse's station, revealed 12 Hydrocodone (a narcotic pain medication) 5 milligram (mg) tablets in the narcotic box with an expiration date of .5/18 . Interview with LPN #1 on 8/29/18 at 9:28 AM, in the conference room, confirmed the 12 Hydrocodone 5mg tablets observed in the 2 & 4 medication cart were expired in May of 2018 and the facility failed to ensure expired medications were not available for resident use.