**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to develop and implement a comprehensive care plan for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to develop and implement a comprehensive care plan for the resident's DNR (do not resuscitate) status after the resident formulated an advance directive and the physician wrote a DNR order. A review of R1's clinical record revealed a Durable Do Not Resuscitate Order form. This review revealed, in part: STOP. Do Not Resuscitate. Durable Do Not Resuscitate Order .Patient's Full Legal Name XXX[DATE] .The patient is capable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment .I hereby direct any and all qualified health care personnel, commencing on the effective date noted above, to withhold cardiopulmonary resuscitation .from the patient in the event of the patient's cardiac or respiratory arrest. I hereby further direct such personnel to provide the patient other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain. The document was signed by the nurse practitioner and R1. A review of R1's provider's orders revealed the following order dated [DATE]: Code Status: DNR (do not resuscitate). A review of R1's comprehensive care plan dated [DATE] failed to reveal any evidence of the resident's DNR status. A review of R1's nursing progress notes revealed the following note dated [DATE] at 4:52 a.m.: CNA (certified nursing assistant) staff alerted nursing staff that they walked in to round on resident and observed him sitting up in a chair beside his dresser with a trash can liner (bag) over his head, with tape around the bag. Bag removed and not able to palpate pulse. Resident placed in bed. Nasal cannula oxygen applied to his nose. 911 called. Administrator and ADON (assistant director of nursing) notified. EMS (emergency medical services) pronounced resident at 12:56 a.m. On [DATE] at 7:32 p.m., CNA #2 was interviewed. She stated she and CNA #3 took care of R1 on [DATE] on the evening/night shift. She stated around time for midnight rounds, she and CNA #3 checked on R1 first, because he had not rung the bell in a while. When they entered the resident's room, the observed the resident slumped over in a chair with a plastic bag taped around his neck. She stated she ran for the nurse (RN [registered nurse] #1), and the three of them got the resident back in the bed. She stated RN #1 immediately started CPR (specifically chest compressions). She concluded: They worked on him until EMS got here. On [DATE] at 7:42 p.m., CNA #3 was interviewed. She stated she assisted CNA #2 in taking care of R1 in the evening on [DATE], and described the same sequence of events that CNA #2 recounted. She stated after CNA #2 ran to get the nurse, RN #1 was the first to get to the room. RN #1 asked CNA #3 to go get the vital sign machine. At that point, LPN #4 entered the room and began chest compressions. CNA #3 stated she called 911, and the two nurses performed CPR, alternating which one was giving chest compressions, until EMS arrived. On [DATE] at 7:50 p.m., RN #1 was interviewed. She stated she was not very familiar with R1, having only cared for him on one shift prior to the evening of [DATE]. She stated one of the aides ran towards her yelling R1's name. She followed the aide back into R1's room and saw him slumped over in the chair with a plastic bag over his head. She stated she checked for a pulse, and could not find one. She stated she tore the plastic bag at the area of R1's nose and mouth, and waited for the other nurse to arrive to get the resident into the bed. She stated LPN #4 arrived in the room and started CPR, and she (RN #1) applied oxygen. She stated one of the aides called 911. She stated LPN #4 asked her to switch out giving compressions, which she did. She stated she and LPN #4 continued with chest compressions until EMS arrived. When asked if she checked R1's code status prior to either nurse beginning CPR, she stated: Everybody kind of knew. I had not seen the DNR paper. I did not know the status at the time. We just wanted to help him. She stated she did not see R1's DNR form until she was assembling paperwork for EMS. She stated she believes LPN #4 and the CNAs knew the resident's code status at the time, but proceeded with CPR anyway. When asked if it is appropriate to administer CPR to a resident who has a signed DNR, and a physician's order for DNR, she stated: When we know they have a DNR, we just stop the CPR. On [DATE] at 9:50 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2 were informed of these concerns. On [DATE] at 10:07 a.m., RN #3, the MDS (minimum data set) coordinator, was interviewed. She stated one of her roles is to oversee the development of a resident's care plan. She stated that normally, a resident's code status is included in the comprehensive care plan, and is an important part of a resident's care. After reviewing R1's care plan, she stated: [R1's code status] is not in the body of his care plan. There are no interventions for implementation. There should have been. A review of the facility policy, Comprehensive Care Plan, revealed, in part: The comprehensive care plan is designed to .incorporate identified needs .reflect the goals and objectives in measured outcomes .respect resident rights. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to develop and implement a comprehensive care plan for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to develop and implement a comprehensive care plan for the resident's DNR (do not resuscitate) status after the resident formulated an advance directive and the physician wrote a DNR order. A review of R1's clinical record revealed a Durable Do Not Resuscitate Order form. This review revealed, in part: STOP. Do Not Resuscitate. Durable Do Not Resuscitate Order .Patient's Full Legal Name XXX[DATE] .The patient is capable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment .I hereby direct any and all qualified health care personnel, commencing on the effective date noted above, to withhold cardiopulmonary resuscitation .from the patient in the event of the patient's cardiac or respiratory arrest. I hereby further direct such personnel to provide the patient other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain. The document was signed by the nurse practitioner and R1. A review of R1's provider's orders revealed the following order dated [DATE]: Code Status: DNR (do not resuscitate). A review of R1's comprehensive care plan dated [DATE] failed to reveal any evidence of the resident's DNR status. A review of R1's nursing progress notes revealed the following note dated [DATE] at 4:52 a.m.: CNA (certified nursing assistant) staff alerted nursing staff that they walked in to round on resident and observed him sitting up in a chair beside his dresser with a trash can liner (bag) over his head, with tape around the bag. Bag removed and not able to palpate pulse. Resident placed in bed. Nasal cannula oxygen applied to his nose. 911 called. Administrator and ADON (assistant director of nursing) notified. EMS (emergency medical services) pronounced resident at 12:56 a.m. On [DATE] at 7:32 p.m., CNA #2 was interviewed. She stated she and CNA #3 took care of R1 on [DATE] on the evening/night shift. She stated around time for midnight rounds, she and CNA #3 checked on R1 first, because he had not rung the bell in a while. When they entered the resident's room, the observed the resident slumped over in a chair with a plastic bag taped around his neck. She stated she ran for the nurse (RN [registered nurse] #1), and the three of them got the resident back in the bed. She stated RN #1 immediately started CPR (specifically chest compressions). She concluded: They worked on him until EMS got here. On [DATE] at 7:42 p.m., CNA #3 was interviewed. She stated she assisted CNA #2 in taking care of R1 in the evening on [DATE], and described the same sequence of events that CNA #2 recounted. She stated after CNA #2 ran to get the nurse, RN #1 was the first to get to the room. RN #1 asked CNA #3 to go get the vital sign machine. At that point, LPN #4 entered the room and began chest compressions. CNA #3 stated she called 911, and the two nurses performed CPR, alternating which one was giving chest compressions, until EMS arrived. On [DATE] at 7:50 p.m., RN #1 was interviewed. She stated she was not very familiar with R1, having only cared for him on one shift prior to the evening of [DATE]. She stated one of the aides ran towards her yelling R1's name. She followed the aide back into R1's room and saw him slumped over in the chair with a plastic bag over his head. She stated she checked for a pulse, and could not find one. She stated she tore the plastic bag at the area of R1's nose and mouth, and waited for the other nurse to arrive to get the resident into the bed. She stated LPN #4 arrived in the room and started CPR, and she (RN #1) applied oxygen. She stated one of the aides called 911. She stated LPN #4 asked her to switch out giving compressions, which she did. She stated she and LPN #4 continued with chest compressions until EMS arrived. When asked if she checked R1's code status prior to either nurse beginning CPR, she stated: Everybody kind of knew. I had not seen the DNR paper. I did not know the status at the time. We just wanted to help him. She stated she did not see R1's DNR form until she was assembling paperwork for EMS. She stated she believes LPN #4 and the CNAs knew the resident's code status at the time, but proceeded with CPR anyway. When asked if it is appropriate to administer CPR to a resident who has a signed DNR, and a physician's order for DNR, she stated: When we know they have a DNR, we just stop the CPR. On [DATE] at 9:50 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2 were informed of these concerns. On [DATE] at 10:07 a.m., RN #3, the MDS (minimum data set) coordinator, was interviewed. She stated one of her roles is to oversee the development of a resident's care plan. She stated that normally, a resident's code status is included in the comprehensive care plan, and is an important part of a resident's care. After reviewing R1's care plan, she stated: [R1's code status] is not in the body of his care plan. There are no interventions for implementation. There should have been. A review of the facility policy, Comprehensive Care Plan, revealed, in part: The comprehensive care plan is designed to .incorporate identified needs .reflect the goals and objectives in measured outcomes .respect resident rights. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow a provider's order to withhold (cardiopulmonary resuscitation) for one of four residents in the survey sample, Resident #1. The findings include: For Resident #1 (R1), the facility staff failed to follow a provider's order when they performed CPR on him after he had executed a DNR (do not resuscitate) form and the provider had written a corresponding order. A review of R1's clinical record revealed a Durable Do Not Resuscitate Order form. This review revealed, in part: STOP. Do Not Resuscitate. Durable Do Not Resuscitate Order .Patient's Full Legal Name XXX[DATE] .The patient is capable of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment .I hereby direct any and all qualified health care personnel, commencing on the effective date noted above, to withhold cardiopulmonary resuscitation .from the patient in the event of the patient's cardiac or respiratory arrest. I hereby further direct such personnel to provide the patient other medical interventions, such as intravenous fluids, oxygen, or other therapies deemed necessary to provide comfort care or alleviate pain. The document was signed by the nurse practitioner and R1. A review of R1's provider's orders revealed the following order dated [DATE]: Code Status: DNR (do not resuscitate). A review of R1's nursing progress notes revealed the following note dated [DATE] at 4:52 a.m.: CNA (certified nursing assistant) staff alerted nursing staff that they walked in to round on resident and observed him sitting up in a chair beside his dresser with a trash can liner (bag) over his head, with tape around the bag. Bag removed and not able to palpate pulse. Resident placed in bed. Nasal cannula oxygen applied to his nose. 911 called. Administrator and ADON (assistant director of nursing) notified. EMS (emergency medical services) pronounced resident at 12:56 a.m. On [DATE] at 7:32 p.m., CNA #2 was interviewed. She stated she and CNA #3 took care of R1 on [DATE] on the evening/night shift. She stated around time for midnight rounds, she and CNA #3 checked on R1 first, because he had not rung the bell in a while. When they entered the resident's room, the observed the resident slumped over in a chair with a plastic bag taped around his neck. She stated she ran for the nurse (RN [registered nurse] #1), and the three of them got the resident back in the bed. She stated RN #1 immediately started CPR (specifically chest compressions). She concluded: They worked on him until EMS got here. On [DATE] at 7:42 p.m., CNA #3 was interviewed. She stated she assisted CNA #2 in taking care of R1 in the evening on [DATE], and described the same sequence of events that CNA #2 recounted. She stated after CNA #2 ran to get the nurse, RN #1 was the first to get to the room. RN #1 asked CNA #3 to go get the vital sign machine. At that point, LPN #4 entered the room and began chest compressions. CNA #3 stated she called 911, and the two nurses performed CPR, alternating which one was giving chest compressions, until EMS arrived. On [DATE] at 7:50 p.m., RN #1 was interviewed. She stated she was not very familiar with R1, having only cared for him on one shift prior to the evening of [DATE]. She stated one of the aides ran towards her yelling R1's name. She followed the aide back into R1's room and saw him slumped over in the chair with a plastic bag over his head. She stated she checked for a pulse, and could not find one. She stated she tore the plastic bag at the area of R1's nose and mouth, and waited for the other nurse to arrive to get the resident into the bed. She stated LPN #4 arrived in the room and started CPR, and she (RN #1) applied oxygen. She stated one of the aides called 911. She stated LPN #4 asked her to switch out giving compressions, which she did. She stated she and LPN #4 continued with chest compressions until EMS arrived. When asked if she checked R1's code status prior to either nurse beginning CPR, she stated: Everybody kind of knew. I had not seen the DNR paper. I did not know the status at the time. We just wanted to help him. She stated she did not see R1's DNR form until she was assembling paperwork for EMS. She stated she believes LPN #4 and the CNAs knew the resident's code status at the time, but proceeded with CPR anyway. When asked if it is appropriate to administer CPR to a resident who has a signed DNR, and a physician's order for DNR, she stated: When we know they have a DNR, we just stop the CPR. On [DATE] at 9:19 a.m., RN #2 was interviewed. She stated code status is listed on the report sheet, which she always carries in her pocked. She stated code status is also listed in the EMR, and is available for review in a pink binder at the desk. She stated if she discovered a resident to be in cardiac or respiratory arrest, she would check their code status. She stated the first place she would look would be her report sheet. She stated if the resident is a DNR, she would try to make sure the resident is comfortable, notify the doctor, and notify the family. She stated if the facility staff administers CPR to a resident who has a signed DNR and a physician's order for DNR, we have violated their rights, their requests. And we haven't followed the order. On [DATE] at 9:37 a.m., ASM (administrative staff member) #2, the director of risk management and staff educator, was interviewed. She stated a resident's code status is on the EMR, in their charting, and on a white board at the desk. She stated if a nurse walks in on a resident who is in cardiac or respiratory arrest, and the resident has a DNR, the nurse will make the resident comfortable, call the doctor, and intervene within the nurse's scope of practice. She stated: We wouldn't do CPR. She stated if the facility staff perform CPR on a resident who has a physician's order for DNR, it's not good. You can end up saving someone who doesn't want to be saved. That person could end up on a ventilator. On [DATE] at 9:50 a.m., ASM (administrative staff member) #1, the administrator, and ASM #2 were informed of these concerns. A review of the facility policy, Physician's Orders, revealed, in part: Physician's orders will be received, noted, and implemented by qualified professional staff. No further information was provided prior to exit.

Based on staff interview, clinical record review, facility document review, and in the course of a complaint investigation, the facility staff failed to inform the resident representative of medication changes for 1 of 4 closed record reviews, Resident #106. For Resident #106, the facility staff failed to notify the resident representative of medication changes including the discontinuation of Seroquel (an antipsychotic medication) and a new order for Risperdal (an antipsychotic medication). The findings included: Resident #106's diagnosis list indicated diagnoses, which included, but not limited to Auditory Hallucinations, Dementia with Behavioral Disturbance, Bilateral Benign Paroxysmal Vertigo, Diabetes Mellitus due to underlying condition with Diabetic Chronic Kidney Disease, Gastro-Esophageal Reflux Disease, and Hypothyroidism. The most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 7/23/20 assigned the resident a brief interview for mental status (BIMS) summary score of 12 out of 15 indicating Resident #106 was moderately cognitively impaired with verbal behavioral symptoms directed toward others exhibited one (1) to three (3) days during the MDS assessment period. Resident #106 was coded for active diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Psychotic Disorder. The resident was also coded as receiving an antipsychotic medication and an antidepressant each day during the past seven (7) days and an antianxiety medication one (1) day during the past seven (7) days. A review of Resident #106's closed clinical record revealed an order for Seroquel 25 mg every morning and 50 mg at bedtime was discontinued and a new order for Risperdal 0.5 mg by mouth at bedtime was started on 7/06/20 for hallucinations. The resident was seen by Geriatric Psychiatry on 7/06/20, the progress note stated in part No significant improvement in (his/her) mental status probably due to (his/her) non-compliance with tx (treatment). Remains verbally agitated. Medication changes included to discontinue Quetiapine (generic for Seroquel) and start Risperidone (generic for Risperdal) oral solution 0.5 mg every bedtime to promote compliance. Surveyor reviewed Resident #106's clinical record and was unable to locate documentation of responsible party notification of the discontinuation of Quetiapine (Seroquel) and the new order for Risperidone (Risperdal). On 4/21/22 at 10:37 am, surveyor met with the vice president of health and wellness (VPHW), admissions, quality assurance registered nurse (QARN), and the quality assurance licensed practical nurse (QALPN) regarding Resident #106's responsible party notification of the 7/06/20 physician orders to discontinue Seroquel and start Risperdal. The QARN acknowledged they also could not find responsible party notification of these order changes and stated if it was not documented, it was not done. Surveyor asked if the responsible party should have been notified of the changes and the QARN stated yes absolutely. Surveyor requested and received the facility policy entitled Truthful Communication with Residents which read in part Policy Statement: Each resident shall be fully informed in a language he or she understands of his or her total health status, including but not limited to, his or her medical condition, a significant change in status, a need to alter his or her treatment significantly, or provide for transfer or discharge of the resident If a resident is incapable of making decisions or fully understanding the information communicated or the resident does not wish to participate, the resident's responsible representative shall be contacted of any decisions that have to be made. However, staff should still meet with the resident to inform him or her what is happening to them. On 4/21/22 at 11:17 am, surveyor met with the VPHW and director of nursing and discussed the concern of Resident #106's responsible party not being notified of medication changes from 7/06/20. No further information regarding this concern was presented to the survey team prior to the exit conference on 4/21/22. This is a complaint deficiency.

Based on staff interview, clinical record review, and during a medication pass and pour observation, the facility staff failed to follow physician orders for 1 of 13 residents, Resident #101. The facility nursing staff administered the medication Finasteride with Resident #101's morning medications when it was ordered to be given at bedtime. The findings included: There was no completed minimum data set (MDS) assessment completed on this resident. The resident was alert and orientated to self and place. Diagnoses included, but were not limited to chronic kidney disease and benign prostate hyperplasia (BPH). 04/20/22 8:28 a.m., the surveyor observed Licensed Practical Nurse (LPN) #2 prepare and administer Resident #101's medications to include the medication Finasteride 5 mg. The residents clinical record included an order for Finasteride 5 mg 1 tab for BPH at bedtime date of order 04/19/22. 04/20/22 10:45 a.m., the surveyor and LPN #2 reviewed the clinical record. LPN #2 stated the order was changed yesterday and was previously given in the morning. Resident #101's clinical record included a progress note dated 04/18/22 12:55 p.m. that read in part Rsd seen on round by .Changing BPH meds to q (every) HS (bedtime/hour of sleep) history of orthostasis . 04/20/22 11:10 a.m., during a meeting with the Administrator and Director of Nursing (DON) the issue regarding Resident #101's Finasteride medication was reviewed. The DON stated the nurse should have checked the medication order. 04/20/22, the facility staff provided the survey team with a copy of their policy titled, MEDICATION TREATMENT ADMINISTRATION. This policy read in part, .The physicians order must be verified before the medication is administered . No further information regarding this issue was provided to the survey team prior to exit conference.

Based on staff interview and clinical record review, the facility staff failed to follow up on a pharmacy recommendation for 1 of 13 Residents, Resident #37. The facility staff failed to obtain the laboratory test thyroid stimulating hormone (TSH) as recommended by the attending physician. The findings included: Section C (cognitive patterns) of Resident #37's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 03/28/22 included a brief interview for mental status (BIMS) summary score of 15 out of a possible 15 points. Diagnoses included, but were not limited to hypothyroidism and anxiety disorder. The clinical record included a pharmacy recommendation dated 11/19/21 requesting a thyroid panel be completed. The attending physician reviewed the pharmacy recommendation on 12/22/21 and documented TSH on 12/27. During the clinical record review, the surveyor was unable to find the results of this lab work. 04/20/22 1:50 p.m., the unit coordinator was asked for the results of the laboratory test. 04/20/21 2:20 p.m., the unit coordinator stated they were unable to find any results for the lab test. Resident #37 was currently taking the thyroid medication Levothyroxine 50 mcg one time a day. 04/20/22 4:05 p.m., during an end of the day meeting with the survey team the Administrator and Director of Nursing (DON) were notified of the issue regarding Resident #37's pharmacy recommendation. No further information regarding this issue was provided to the survey team prior to the exit conference.

Based on staff interviews, facility document review, and clinical record review, the facility staff failed ensure an accurate clinical record for 1 of 4 closed records, Resident #146. For Resident #146, the facility staff failed to document the reason a prn (as needed) medication was administered or alternate methods of pain relief offered before administering the medication. The findings were: Resident #146's diagnosis list included, but was not limited to, non-traumatic intracranial hemorrhage, adult failure to thrive, benign prostatic hyperplasia, other injury of unspecified kidney, and atrial fibrillation. The quarterly minimum data set with an assessment reference date of 10/20/2021 coded the resident a 15 out of 15 for a brief interview for mental status summary score. The resident's care plan included a problem category of pain which read in part that the resident had recently been admitted to hospice care and the resident often had a difficult time differentiating between pain and discomfort related to a rash on his body. The approaches listed for this problem included, but were not limited to, giving pain medication as needed, re-evaluating pain status after administering medication for effectiveness, and offering non-pharmacological interventions for pain such as heat, ice, music, massage and/or repositioning. Resident #146's clinical record review was a closed record. The resident's medication administration record (MAR) was reviewed on 04/20/2022. An order for morphine concentration - Schedule II solution; 100 mg/5mL (20mg/mL); Amount to Administer: 0.25ml orally, was noted with a frequency of every 2 hours as needed. Special instructions read to administer the 0.25ml sublingually every 2 hrs as needed for pain. The morphine order had a start date of 10/25/2021 with an open end date. The registered nurse (RN#1) documented she administered Resident #146 morphine on 12/07/2021 at 7:57 p.m. and 11:35 p.m. and again on the same shift, 12/08/2021 at 1:44 a.m. and 4:05 a.m. The nurse documented the morphine was given for pain but there was no documentation that described the resident's pain or his request for the medication. There was no documentation of any alternative method of pain relief offered prior to providing morphine. RN#1 was interviewed via phone on 04/20/2022. The nurse stated she felt the resident was in pain based on his behavior and his affirmative response when asked whether he wanted pain medication. She acknowledged not documenting a description of Resident #146's behavior or conversation as well as her attempts at other things she tried to help comfort the resident. When asked why she did not document those encounters, the nurse stated she must have been busy since she normally does document those observations and/or pain medication requests. The director of nursing (DON) was interviewed on 04/20/2022 at 10:45 a.m. She reported her expectation was that nurses would describe what actions they attempted to comfort a resident prior to administering a prn medication, then describe why a prn medication was given followed up with the effectiveness of the medication dose. The DON acknowledged RN#1 had not documented the expected information for Resident #146's prn morphine doses on 12/07/2021 and 12/08/2021. The DON provided evidence of staff nurses' education regarding documenting prn medications dated 12/14/2021 titled, PRN documentation. The DON stated the education started on 12/14/2021 and continued on subsequent dates in order to educate all facility nurses. No further information was provided prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical review, the facility failed to create a comprehensive assessment for 1 of 16 residents (Resident #35). Resident #35 was admitted to the facility on [DATE] with diagnoses including hypertension, dementia, and anxiety disorder. On the admission minimum data set assessment the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behavior symptoms. On the most recent quarterly minimum data set assessment with assessment reference date 1/8/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident scored 6/27 on the resident mood interview. During an interview on 2/5/19, the resident reported the only concern with care was not getting enough of the food, which was bad. 02/07/19 11:17 AM PRN ativan ordered on 10/17/18 reviewed 12/26/18 and discontinued as staff reported no use for 2 weeks. Clinical record review on 2/7/19 revealed the resident was readmitted [DATE]. Medication orders included Buspar 5 mg three times per day for anxiety and seroquel 25 mg twice per day since admission and ativan as needed. The physician declined (graduated dose reduction) GDRs on both medications due to history of symptom instability. The surveyor was unable to locate documentation of symptoms being treated by the seroquel. There were no behavior or symptom tracking orders or nurse's notes referencing symptoms that might be considered signs of psychosis. The resident's nurse was unable to describe the symptoms for which the resident was taking antipsychotic medications. The surveyor spoke with the director of nursing (DON) about the issue. The DON was able to locate 2 Behavior Monitoring Sheets. One was blank except for documenting trazodone and lorazepam as medications the resident was receiving. No targeted symptoms were indicated. The second sheet indicated monitoring for 14-yelling and 16-c/o anxiety. The form indicated the resident c/o anxiety on 11/15/18 and received a 1-on-1 visit, rest in bed, and ativan and that the interventions were effective. No staff member was able to report the symptoms for which the antipsychotic medication seroquel was ordered. The Comprehensive Care plan for 1/24/16 through 10/19/17 did not document psychosis, psychotic disorder, or use of antipsychotic medication or symptoms of psychosis or delusion. The care plan initiated 10/19/17 documented I also have a history of psychosis for which I also take medication. The surveyor has been unable to locate any expression of symptoms for which the resident was taking an antipsychotic medication other than the physician's statement increased risk of psychiatric instability. During a summary meeting on 2/7/19, the surveyor reported to the administrator and DON the concern that the comprehensive assessment process had not resulted in a comprehensive care plan that documented and addressed the symptoms being treated by antipsychotic, antidepressant, and antianxiety medication and that staff were able to articulate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, facility staff failed to ensure a resident with dementia was treated with psychotropic medications only when targeting specific symptoms and that use is monitored for efficacy, risks and harm for 1 of 16 residents in the survey sample (Resident #35). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses including hypertension, dementia, and anxiety disorder. On the admission minimum data set assessment the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behavior symptoms. On the most recent quarterly minimum data set assessment with assessment reference date 1/8/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident scored 6/27 on the resident mood interview. During an interview on 2/5/19, the resident reported the only concern with care was not getting enough of the food, which was bad. Clinical record review on 2/7/19 revealed the resident was readmitted [DATE]. Medication orders included Buspar 5 mg three times per day for anxiety and seroquel 25 mg twice per day since admission and ativan as needed. The physician declined GDRs on both medications due to history of symptom instability. The surveyor was unable to locate documentation of symptoms being treated by the seroquel. There were no behavior or symptom tracking orders or nurse's notes referencing symptoms that might be considered signs of psychosis. The resident's nurse was unable to describe the symptoms for which the resident was taking antipsychotic medications. The surveyor spoke with the director of nursing (DON) about the issue. The DON was able to locate 2 Behavior Monitoring Sheets. One was blank except for documenting trazodone and lorazepam as medications the resident was receiving. No targeted symptoms were indicated. The second sheet indicated monitoring for 14-yelling and 16-c/o anxiety. The form indicated the resident c/o anxiety on 11/15/18 and received a 1-on-1 visit, rest in bed, and ativan and that the interventions were effective. No staff member was able to report the symptoms for which the antipsychotic medication seroquel was ordered. The Comprehensive Care plan for 1/24/16 through 10/19/17 did not document psychosis, psychotic disorder, or use of antipsychotic medication or symptoms of psychosis or delusion. The care plan initiated 10/19/17 documented I also have a history of psychosis for which I also take medication. The surveyor has been unable to locate any expression of symptoms for which the resident was taking an antipsychotic medication other than the physician's statement increased risk of psychiatric instability. There were no target symptoms or symptom abatement strategies in the care plan. The administrator and director of nursing were notified of the concern that the resident's care plan did not address dementia and the use of psychotropic and antipsychotic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to appropriately address gradual dose reductions of psychotropic medications for 1 of 16 residents in the survey sample (Resident #35). The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses including hypertension, dementia, and anxiety disorder. On the admission minimum data set assessment the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behavior symptoms. On the most recent quarterly minimum data set assessment with assessment reference date 1/8/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident scored 6/27 on the resident mood interview. 02/07/19 02:11 PM The resident started on seroquel 12.5 mg q am and 15 mg q hs on 2/3/17 after a psychiatric note indicated the resident was reporting seeing bugs that weren't there and had written a postcard to the FBI to complain about the monitor in her head. A second order to increase to 25 mg q AM and QPM on 3/9/17. There are no nursing notes concerning either of the items in the 2/3 physician note and there are no behavior monitoring sheets that indicate any incidents occurred during the Jan-[DATE]-17 time period. 02/07/19 02:41 PM Spoke with DON (director of nursing) about concern that the record does not document any symptoms except one psychiatrist note written the day the antipsychotic was ordered, with no documentation of symptoms leading up to the increase in the dose on 3/9/17. The DON (director of nursing) said she remembered the resident used to talk about the CIA a lot. The surveyor noted that no staff members had documented that symptom. The resident's care plan documented a history of psychosis and taking medication to treat it. There were no target symptoms or symptom abatement strategies. On 2/7/18 at 3:52 pm, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 2/7/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to obtain the physician ordered x-ray for 1 of sixteen residents (Resident #20). The findings included: The facility staff failed to obtain a chest x-ray with 2 views as ordered by the physician for Resident #20 and failed to inform the physician that a single view was obtained instead of the 2 view as ordered. The clinical record of Resident #20 was reviewed 2/5/19 through 2/7/19. Resident #20 was admitted to the facility 10/15/18 with diagnoses that included but not limited to adult failure to thrive, chronic depression, disruptive behavior, agitation, atrial fibrillation, fractured right femur neck, vascular dementia with behavioral disturbances, hypertension, and chronic diastolic heart failure. Resident #20's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 12/3/18 assessed the resident with a brief interview for mental status (BIMS) as 9/15. Resident #20 had no behavioral signs or symptoms, no signs or symptoms of delirium, or psychosis. A telephone order dated 10/26/18 read C (chest) x-ray 2 view for gen (generalized) weakness. I am not feeling well per resident (diminished lung sounds, low level 90-91 % sats (oxygen saturation). The surveyor reviewed the results of the chest x-ray obtained 10/26/18. The results read Chest X-ray 1V (view): Chest AP (anterior/posterior): AP chest reveal cardiac silhouette is normal in size. Bibasilar infiltrates with small bilateral effusions present. IMPRESSION: Interval development of bibasilar infiltrates and small pleural effusion since 2-09-2018. The surveyor informed the administrative staff of the above finding on 2/6/19 at 4:05 p.m. The director of nursing (DON) provided the surveyor with documentation from the x-ray company on 2/7/19 at 8:00 a.m. The DON stated the x-ray technician (tech) was unable to do a 2 view of the chest due to unresponsiveness. The note read, Hi DON, Our tech was unable to perform the lateral view ordered for Resident #20 on [DATE]. What follows is the internal note our tech made regarding this patient: Patient unresponsive, held for view. The surveyor reviewed the interdisciplinary progress notes for 10/26/18 were reviewed. The note timed 0840 read N.O. (new order) C x-ray written. MD (medical doctor) and responsible party aware. 10:15 Late entry for 0700. BP (blood pressure) 148/90, T (temperature) 97.8, R (respirations) 22, P (pulse) 69, O2 (oxygen) sats (saturations) 90. Resident appears lethargic but easily awakens. Able to answer with a yes and no. Then goes back to sleep again. Breathing even and unlabored. Lung sounds diminished throughout all fields. Resident stated, I am not feeling well. No SOB (shortness of breath) /distress noted. For breakfast, resident was moderate assist. C.N.A. (certified nursing assistant) and resident takes turn to put the fork with food in her mouth. No coughing noted on every bite at this time. The director of nursing was asked if the physician should be informed of the inability to obtain the 2-view chest x-ray since the order was current. The DON stated Yes. No further information was provided prior to the exit conference on 2/7/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to develop and or implement a patient centered comprehensive care plan for Resident #31, which included targeted behaviors. The resident was readmitted to the facility on [DATE] with the following diagnoses, but not limited to anemia, high blood pressure, Dementia, Parkinson's disease, depression and psychotic disorder. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/29/12, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15. Resident #31 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. During the clinical record review on 2/6/19, the surveyor noted that Resident #31 was receiving the following physician ordered medications: Risperidone 0.25 mg (milligram) 1 tablet by mouth two times a day for psychosis. Zoloft 75 mg by mouth one time a day for depression. The surveyor reviewed the comprehensive care plan for Resident #31. The comprehensive care plan contained the following interventions: .Give me my medication as ordered. Monitor me for side effects from my medication. Monitor me for changes in my mood and/or behavior. Notify my doctor if it appears my medication is not working . The surveyor requested and received copies of the Behavior/Intervention Monitoring sheets. These sheets were dated for 11/1/18 through 2/6/19. Paranoia and delusions were documented for behavioral symptom codes. However, these sheets were blank and had no documentation of the targeted behaviors to assess for with each of the above documented medications. The surveyor also reviewed the nurse's notes and there was no targeted behaviors symptoms documented. The surveyor notified the administrative team on 2/6/19 at 4:05 pm of the above documented findings. The surveyor requested and received the facility's policy on behavioral monitoring. The policy titled Behaviors Identification and Interventions read in part .Residents with problematic behavioral symptoms will be promptly assessed and monitored by professional staff. Causative factors influencing behavioral will be identified. Management and appropriate behavioral interventions will be care planned, implemented and re-evaluated as changes occur . No further information was provided to the surveyor prior to the exit conference on 2/7/19. 3. The facility staff failed to develop a patient centered comprehensive care plan for Resident #49, which included targeted behaviors. Resident #49 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to atrial fibrillation, high blood pressure, stroke, dementia and anxiety. On the admission, MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/7/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 5 out of a possible score of 15. Resident #49 was also coded as requiring extensive assistance of 1 staff member for dressing and limited assistance from 1 staff member for personal hygiene. The resident was also coded as being totally dependent on 1 staff member for bathing. On 2/5/19 at 2:20 pm, the surveyor noted the following physician's order that included: Xanax 0.5 mg (milligram) 1 tablet by mouth two times a day for anxiety Seroquel 25 mg po (by mouth) at bedtime. The surveyor reviewed the clinical record for Resident #49 on 2/5/19 and 2/6/19 The surveyor also reviewed the comprehensive care plan for Resident #49. For Psychotropic drug use, the surveyor noted the following interventions: .Give me my medication as ordered. Monitor me for side effects from my medication. Monitor me for changes in mood and/or behavior . The surveyor notified the administrative team on 2/6/19 at 4:05 pm of the above documented findings. The surveyor requested and received the facility's policy on behavioral monitoring. The policy titled Behaviors Identification and Interventions read in part .Residents with problematic behavioral symptoms will be promptly assessed and monitored by professional staff. Causative factors influencing behavioral will be identified. Management and appropriate behavioral interventions will be care planned, implemented and re-evaluated as changes occur . No further information was provided to the surveyor prior to the exit conference on 2/7/19. 4. The facility staff failed to implement a person centered comprehensive care plan with targeted behaviors, goals and outcomes for psychotropic medication for depression and decreased appetite identified for Resident #15. The clinical record of Resident #15 was reviewed 2/5/19 through 2/7/19. Resident #15 was admitted to the facility 9/13/17 with diagnoses that included but not limited to nausea with vomiting, generalized muscle weakness, gastroesophageal reflux disease with esophagitis, hypokalemia, iron deficient anemia, history of kidney stones, left hip surgery, chronic depression, and bilateral lower quadrant pain. Resident #15's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/27/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. There were no assessed signs of delirium, psychosis, or behaviors that affected others. Resident #15's February 2019 physician orders were reviewed. Resident #15 had orders and received Remeron 7.5 mg (milligrams) tablet one time a day at bedtime for decreased appetite/weight loss (start date 4/14/18) and Citalopram 20 mg tablet by mouth one time a day for depression (start date 4/14/18). Resident #15 had received both Remeron and Celexa since 4/14/18. The surveyor reviewed the current comprehensive care plan on 2/6/19. One Concern and Strength dated 9/10/18 read, I have a history of depression. I take medicine for this. My preference for care read 1. Give my med (medication) as ordered. 2. Monitor me for s/e (side effects) from my medicine. 3. Monitor me for changes in mood and or behavior. 4. I look forward to visits from my daughter. A second Concern and Strength dated 9/5/2018 read 1. Watch me to make sure my depression does not get any worse. 2. Administer my medications as ordered. 3. I would like my family to visit as much as possible. The current person centered care comprehensive care plan did not identify targeted behaviors, outcomes and goals for Citalopram (Celexa) or Remeron. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Citalopram and Remeron were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor reviewed the behavior/intervention monitoring tool for Resident #15. On the tool, crying out and c/o (complaints of) depression were circled under the behavioral symptoms codes. The surveyor informed the administrative staff of the absence to develop a person-centered care-plan with targeted behaviors, goals and desired outcomes for the use of Citalopram and Remeron to treat Resident #15's depression and decreased appetite on 2/7/19 at 3:52 p.m. The surveyor reviewed the facility policy titled Behaviors Identification and Interventions on 2/7/19. The policy read in part: Assessment of identified behaviors will be documented in (but not limited to) nursing notes, behavior tracking forms and social service progress notes to help clarify the underlying cause of the behavior and help develop effective management intervention. The Care Plan will identify behavior problems, have measurable goals, appropriate interventions and be coordinated with the interdisciplinary team, resident and family. No further information was provided prior to the exit conference on 2/7/19. 5. The facility staff failed to implement a person centered comprehensive care plan with targeted behaviors, goals and outcomes identified for Resident #12 with the use of psychotropic medications (anti-anxiety medications and anti-depressant medication). The clinical record of Resident #12 was reviewed 2/5/19 through 2/7/19. Resident #12 was admitted to the facility 10/1/16 and readmitted [DATE] with diagnoses that included but not limited to urinary tract infection, diabetes, dehydration, weakness, constipation, abnormal weight loss, atrial fibrillation, rheumatoid arthritis, depression, chronic pain syndrome, adult failure to thrive, and osteoporosis. Resident #12's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/9/18 assessed the resident with a BIMS (brief interview for mental status) as 11/15. The resident had no signs or symptoms of delirium, psychosis or behaviors that affected others. Resident #12's February 2019 physician orders included Citalopram 10 mg (milligrams) 1 tablet by mouth one time a day in the morning for depression (start date 11/8/18) and Lorazepam 0.5 mg 1 tablet by mouth one time a day at bedtime for anxiety (start date 10/8/18). Resident #12 received both Citalopram and Lorazepam since November 2018. Resident #12's current comprehensive care plan dated 8/14/18 had the following My Concerns and my strengths for 8/14/18. I have a history of anxiety and depression. I take medicine for this. My preference for care 1. Give me my medication as ordered. 2. Monitor me for s/e (side effects) from my medications 3. Monitor me for changes in mood and /or behaviors. A second I Care Plan dated 8/9/18 read I have a diagnosis of depression and anxiety. Occasionally I have trouble concentrating. 1. Observe me to make sure my mood remains stable and my daily needs are met. 2. I want my family to visit as much as possible. 3. I want to socialize with others and participate in the activities of my choice. 4. Administer my medications as ordered. The current comprehensive care plan did not identify person centered targeted behaviors, goals, and outcomes for the use of Lorazepam (Ativan) and Citalopram. The undated behavior/intervention monitoring tools were circled for crying out and c/o (complains of) anxiety as behavior symptoms codes. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Citalopram and Ativan were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor informed the administrative staff of the absence to develop a care-plan with targeted behaviors, goals and desired outcomes for the use of Citalopram and Ativan to treat Resident #12's depression and anxiety on 2/7/19 at 3:52 p.m. The surveyor reviewed the facility policy titled Behaviors Identification and Interventions on 2/7/19. The policy read in part: Assessment of identified behaviors will be documented in (but not limited to) nursing notes, behavior tracking forms and social service progress notes to help clarify the underlying cause of the behavior and help develop effective management intervention. The Care Plan will identify behavior problems, have measurable goals, appropriate interventions and be coordinated with the interdisciplinary team, resident and family. No further information was provided prior to the exit conference on 2/7/19. 6. The facility staff failed to implement a person centered comprehensive care plan with targeted behaviors, outcomes and goals identified for Resident #20 and the use of psychotropic medication. The clinical record of Resident #20 was reviewed 2/5/19 through 2/7/19. Resident #20 was admitted to the facility 10/15/18 with diagnoses that included but not limited to adult failure to thrive, chronic depression, disruptive behavior, agitation, atrial fibrillation, fractured right femur neck, vascular dementia with behavioral disturbances, hypertension, and chronic diastolic heart failure. Resident #20's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 12/3/18 assessed the resident with a brief interview for mental status (BIMS) as 9/15. Resident #20 had no behavioral signs or symptoms, no signs or symptoms of delirium, or psychosis. Resident #20's February physician orders 2019 included Escitalopram 10 mg 1 tablet by mouth one time a day for depression (start date 12/11/18), Mirtazapine 7.5 mg 1 tablet by mouth one time a day at bedtime for poor appetite and Lorazepam gel 1 mg (milligram)/ml (milliliter) Apply topically every 6 hours as needed for psychosis/agitation/anxiety (start date 12/20/18). The surveyor reviewed Resident #20's current comprehensive care plan dated 12/3/18. Problem areas included one for mood state with long term goal to have a peaceful sleep and approaches to use were to turn on my white noise machine at night and assure me that my roommate shares the room with me and that I am safe. Also identified as a problem area for mood state that the resident had symptoms of depressionm, a diagnosis of anxiety which is managed by daily medication. Approaches included watch me to make sure my depression does not get any worse, refer me to see the doctor to assess my mood, want my family to visit as much as possible, administer my medications as ordered, and provide me with emotional support as needed. Resident #20 also had an area dated 12/5/18 for psychotropic drug use with long term goal to show a stable mood and socialize with others. Approaches included give me my medication as ordered, monitorme for side effects from my medication, and monitor me for changes in mood and/or behavior. The current comprehensive care plan did not identify specific targeted behaviors for the medications, long term measurable goals or individualized approaches to care. The surveyor reviewed the undated behavior/intervention monitoring sheet for Ativan, Lexapro and Remeron. The behavioral symptoms coded were crying out and yelling out. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Citalopram and Ativan were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor informed the administrative staff of the absence to develop a care-plan with targeted behaviors, goals and desired outcomes for the use of Escitalopram, Remeron, and Ativan to treat Resident #20's depression and anxiety on 2/7/19 at 3:52 p.m. The surveyor reviewed the facility policy titled Behaviors Identification and Interventions on 2/7/19. The policy read in part: Assessment of identified behaviors will be documented in (but not limited to) nursing notes, behavior tracking forms and social service progress notes to help clarify the underlying cause of the behavior and help develop effective management intervention. The Care Plan will identify behavior problems, have measurable goals, appropriate interventions and be coordinated with the interdisciplinary team, resident and family. No further information was provided prior to the exit conference on 2/7/19. 7. The facility staff failed to implement a person centered comprehensive care plan with targeted behaviors identified for Resident #44 for the use of psychotropic medication. The clinical record of Resident #44 was reviewed 2/5/19 through 2/7/19. Resident #44 was admitted to the facility 1/18/18 with diagnoses that included but not limited to diabetes mellitus, urinary tract infection, constipation, abnormal weight loss, cerebrovascular accident (CVA), coronary artery disease (CAD), atrial fibrillation, hypertension, gastro esophageal reflux disease, and chronic obstructive pulmonary disease. Resident #44's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/24/19 assessed the resident with a BIMS (brief interview for mental status) as 13/15. Resident #44 was without signs or symptoms of delirium, behaviors affecting others or psychosis. Resident #44's February 2019 physician orders included orders for Valium 2 mg (milligrams) 1 tablet by mouth one time a day for vertigo start date 12/3/2018, Escitalopram 5 mg 1 tablet by mouth one time a day at bedtime for depression start date 1/7/2019 and Quetiapine (Seroquel) 25 mg (1/2tablet) by mouth one time a day at bedtime for agitation d/t (due to psychosis) start date 4/13/2018. The surveyor reviewed the current comprehensive care plan for Resident #44 on 2/6/19. The person centered care plan identified a problem area for psychotropic drug use with long term goals of maintaining a stable mood and approaches to use give me my medication as ordered, monitor me for side effects from my medication, and monitor me for changes in mood and/or behavior. A second care plan identified an issue with mood long term goal was to be comfortable and satisfied and approaches included watch me to make sure my mood does not get any worse, have my family to visit as much as possible, especially my daughter and great granddaughter, and I enjoy playing Bingo and going to wine/cheese social. Please continue to remind me as needed about these events and encourage me to go. The current comprehensive care plan for Resident #44 did not have person centered targeted behaviors, measurable goals or individualized approaches to care. The undated behavior/intervention monitoring sheets had the following behavioral symptoms circled-crying out and yelling out. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Escitalopram, Diazepam, and Seroquel were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor informed the administrative staff of the absence to develop a care-plan with targeted behaviors, goals and desired outcomes for the use of Escitalopram, Diazepam, and Seroquel to treat Resident #44's on 2/7/19 at 3:52 p.m. The surveyor reviewed the facility policy titled Behaviors Identification and Interventions on 2/7/19. The policy read in part: Assessment of identified behaviors will be documented in (but not limited to) nursing notes, behavior tracking forms and social service progress notes to help clarify the underlying cause of the behavior and help develop effective management intervention. The Care Plan will identify behavior problems, have measurable goals, appropriate interventions and be coordinated with the interdisciplinary team, resident and family. No further information was provided prior to the exit conference on 2/7/19. Based on staff interview and clinical record review, the facility staff failed to develop and or implement a patient centered comprehensive care plan for 7 of 16 residents in the survey sample (Residents #35, 31, 49, 15, 12, 20, and 44). The findings included: 1. For Resident #35, facility staff failed to develop a comprehensive care plan that addressed the symptoms for which the resident was treated with antianxiety, antidepressant, and antipsychotic medications. Resident #35 was admitted to the facility on [DATE] with diagnoses including hypertension, dementia, and anxiety disorder. On the admission minimum data set assessment the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behavior symptoms. On the most recent quarterly minimum data set assessment with assessment reference date 1/8/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident scored 6/27 on the residentr mood interview. During an interview on 2/5/19, the resident reported the only concern with care was not getting enough of the food, which was bad. Clinical record review on 2/7/19 revealed the resident was readmitted [DATE]. Medication orders included Buspar 5 mg three times per day for anxiety and seroquel 25 mg twice per day since admission and ativan as needed. The physician declined GDRs on both medications due to history of symptom instability. The surveyor was unable to locate documentation of symptoms being treated by the seroquel. There were no behavior or symptom tracking orders or nurse's notes referencing symptoms that might be considered signs of psychosis. The resident's nurse was unable to describe the symptoms for which the resident was taking antipsychotic medications. The surveyor spoke with the director of nursing (DON) about the issue. The DON was able to locate 2 Behavior Monitoring Sheets. One was blank except for documenting trazodone and lorazepam as medications the resident was receiving. No targeted symptoms were indicated. The second sheet indicated monitoring for 14-yelling and 16-c/o anxiety. The form indicated the resident c/o anxiety on 11/15/18 and received a 1-on-1 visit, rest in bed, and ativan and that the interventions were effective. No staff member was able to report the symptoms for which the antipsychotic medication seroquel was ordered. The Comprehensive Care plan for 1/24/16 through 10/19/17 did not document psychosis, psychotic disorder, or use of antipsychotic medication or symptoms of psychosis or delusion. The care plan initiated 10/19/17 documented I also have a history of psychosis for which I also take medication. The surveyor has been unable to locate any expression of symptoms for which the resident was taking an antipsychotic medication other than the physician's statement increased risk of psychiatric instability. There were no target symptoms or symptom abatement strategies in the care plan. The administrator and director of nursing were notified of the concern that the resident's care plan did not address the use of psychotropic and antipsychotic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to monitor behaviors while Resident #31 was receiving psychotropic medications. Resident was readmitted to the facility on [DATE] with the following diagnoses, but not limited to anemia, high blood pressure, Dementia, Parkinson's disease, depression and psychotic disorder. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/29/12, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15. Resident #31 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. During the clinical record review on 2/6/19, the surveyor noted that Resident #31 was receiving the following physician ordered medications: Risperidone 0.25 mg (milligram) 1 tablet by mouth two times a day for psychosis. Zoloft 75 mg by mouth one time a day for depression. The surveyor performed a clinical record review on Resident #31 on 2/6 and 2/7/19. During this review, the surveyor noted that the resident was being given Zoloft daily for depression and Risperidone twice a day for psychosis. The surveyor reviewed the nurses' notes and MAR (Medication Administration Record) for the months of January and February 2019. There was no documentation of behaviors while receiving these medications. The surveyor notified the administrative team of the above documented findings on 2/6/19 at 4:05 pm in the conference room. The surveyor requested and received the facility's policy on behavioral monitoring. The policy titled Behaviors Identification and Interventions read in part .Residents with problematic behavioral symptoms will be promptly assessed and monitored by professional staff. Causative factors influencing behavioral will be identified. Management and appropriate behavioral interventions will be care planned, implemented and re-evaluated as changes occur . No further information was provided to the surveyor prior to the exit conference on 2/7/19 3. The facility staff failed to monitor behaviors while Resident #49 was receiving psychotropic medications. Resident #49 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to atrial fibrillation, high blood pressure, stroke, dementia and anxiety. On the admission, MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/7/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 5 out of a possible score of 15. Resident #49 was also coded as requiring extensive assistance of 1 staff member for dressing and limited assistance from 1 staff member for personal hygiene. The resident was also coded as being totally dependent on 1 staff member for bathing. On 2/6/19, the surveyor noted the following physician's order that included: Xanax 0.5 mg (milligram) 1 tablet by mouth two times a day for anxiety Seroquel 25 mg po (by mouth) at bedtime. The surveyor reviewed the clinical record for Resident #49 on 2/5/19 and 2/6/19.The surveyor also reviewed the comprehensive care plan for Resident #49. For Psychotropic drug use, the surveyor noted the following interventions: .Give me my medication as ordered. Monitor me for side effects from my medication. Monitor me for changes in mood and/or behavior . The surveyor notified the administrative team on 2/6/19 at 4:05 pm of the above documented findings. The surveyor requested and received the facility's policy on behavioral monitoring. The policy titled Behaviors Identification and Interventions read in part .Residents with problematic behavioral symptoms will be promptly assessed and monitored by professional staff. Causative factors influencing behavioral will be identified. Management and appropriate behavioral interventions will be care planned, implemented and re-evaluated as changes occur . No further information was provided to the surveyor prior to the exit conference on 2/7/19. 4. The facility staff failed to ensure Resident #15 was free of unnecessary medications. Resident #15 was administered Remeron and Celexa without identified targeted behaviors and monitoring for effects/side effects. The clinical record of Resident #15 was reviewed 2/5/19 through 2/7/19. Resident #15 was admitted to the facility 9/13/17 with diagnoses that included but not limited to nausea with vomiting, generalized muscle weakness, gastroesophageal reflux disease with esophagitis, hypokalemia, iron deficient anemia, history of kidney stones, left hip surgery, chronic depression, and bilateral lower quadrant pain. Resident #15's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/27/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. There were no assessed signs of delirium, psychosis, or behaviors that affected others. Resident #15's February 2019 physician orders were reviewed. Resident #15 had orders and received Remeron 7.5 mg (milligrams) tablet one time a day at bedtime for decreased appetite/weight loss (start date 4/14/18) and Citalopram 20 mg tablet by mouth one time a day for depression (start date 4/14/18). Resident #15 had received both Remeron and Celexa since 4/14/18. The surveyor reviewed the current comprehensive care plan on 2/6/19. One Concern and Strength dated 9/10/18 read, I have a history of depression. I take medicine for this. My preference for care read 1. Give my med (medication) as ordered. 2. Monitor me for s/e (side effects) from my medicine. 3. Monitor me for changes in mood and or behavior. 4. I look forward to visits from my daughter. A second Concern and Strength dated 9/5/2018 read 1. Watch me to make sure my depression does not get any worse. 2. Administer my medications as ordered. 3. I would like my family to visit as much as possible. The current person centered care comprehensive care plan did not identify targeted behaviors, outcomes and goals for Citalopram (Celexa) or Remeron. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Citalopram and Remeron were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor reviewed the undated behavior/intervention monitoring tool for Resident #15. On the tool, crying out and c/o (complaints of) depression were circled under the behavioral symptoms codes. However, there was no evidence of crying out or depression documented on the tool. The Resident Progress Notes completed for the quarterly MDS were reviewed. The 11/29/18 Social Services Quarterly Assessment read Resident #15 participated in the BIMS and mood assessment interviews on 11/26/18. She scored a 15/15 on the BIMS. No signs or symptoms of delirium present. Per the mood assessment, she reported no symptoms. Resident #15 is prescribed an antidepressant for depression. The quarterly nutrition assessment dated [DATE] read CBW (current body weight) 138.7 # (pounds) reflects a desired 2.7# weight gain since last review. No significant weight change. Effectiveness of appetite stimulant. Resident #15 was last seen by geriatric psychiatry on 8/20/18. The note read in part Patient's current tx (treatment) and nursing report reviewed. Has no specific complaint. No SE (side effects) noted. No psychotic symptoms. Stable. No acute sx (symptoms). Resident #15's physician had declined a gradual dose reduction (GDR) in March 2018 and in September 2018, stating increased risk psych instability; however, the behavior monitoring sheets have no documentation of crying out or depression. The DON (director of nursing) stated the staff document by exception-only document what they see or hear. The surveyor interviewed Resident #15 on 2/5/19 at 2:56 p.m. When asked about mood, the resident stated, I am always happy. The surveyor informed the administrative staff of the use of Citalopram and Remeron to treat Resident #15's on 2/7/19 at 3:52 p.m. without the use of monitoring/documentation to support both. The surveyor requested the facility policy on psychotropic drug use. The surveyor reviewed the facility policy titled Psychotropic Drug Use on 2/7/19. The policy read in part 2. Residents who receive psychotropic medications are required to receive gradual dose reductions and behavioral interventions, unless contraindicated, in an effort to discontinue use of the psychotropic medications. No further information was provided prior to the exit conference on 2/7/19. 5. The facility staff failed to ensure Resident #12 was free of unnecessary medications. Resident #12 was administered Citalopram and Lorazepam (Ativan) without monitoring for effects and side effects and without targeted behaviors. The clinical record of Resident #12 was reviewed 2/5/19 through 2/7/19. Resident #12 was admitted to the facility 10/1/16 and readmitted [DATE] with diagnoses that included but not limited to urinary tract infection, diabetes, dehydration, weakness, constipation, abnormal weight loss, atrial fibrillation, rheumatoid arthritis, depression, chronic pain syndrome, adult failure to thrive, and osteoporosis. Resident #12's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/9/18 assessed the resident with a BIMS (brief interview for mental status) as 11/15. The resident had no signs or symptoms of delirium, psychosis or behaviors that affected others. Resident #12's February 2019 physician orders included Citalopram 10 mg (milligrams) 1 tablet by mouth one time a day in the morning for depression (start date 11/8/18) and Lorazepam 0.5 mg 1 tablet by mouth one time a day at bedtime for anxiety (start date 10/8/18). Resident #12 received both Citalopram and Lorazepam since November 2018. Resident #12's current comprehensive care plan dated 8/14/18 had the following My Concerns and my strengths for 8/14/18. I have a history of anxiety and depression. I take medicine for this. My preference for care 1. Give me my medication as ordered. 2. Monitor me for s/e (side effects) from my medications 3. Monitor me for changes in mood and /or behaviors. A second I Care Plan dated 8/9/18 read I have a diagnosis of depression and anxiety. Occasionally I have trouble concentrating. 1. Observe me to make sure my mood remains stable and my daily needs are met. 2. I want my family to visit as much as possible. 3. I want to socialize with others and participate in the activities of my choice. 4. Administer my medications as ordered. The current comprehensive care plan did not identify person centered targeted behaviors, goals, and outcomes for the use of Lorazepam (Ativan) and Citalopram. The undated behavior/intervention monitoring tools were circled for crying out and c/o (complains of) anxiety as behavior symptoms codes. The behavior/intervention monitoring sheet did not have any documentation of Resident #12 having crying out or c/o anxiety. There was no documentation to support the use of both Lorazepam and Citalopram (Celexa). The surveyor reviewed the quarterly MDS progress notes. The social services quarterly note dated 11/12/18 read Resident #12 participated in the BIMS mood assessment interview on 11/7/2018. Resident #12 scored an 11/15 on the BIMS; she could not recall two words. No signs or symptoms of delirium present. Per the mood assessment, Resident #12 reported feeling tired. Resident #12 is prescribed an antidepressant and anti-anxiety medication with no adverse effects noted. No behaviors noted. The surveyor reviewed the interdisciplinary progress notes from December 2018 through 2/6/19 and found no evidence to support the use of Celexa and Ativan. Documentation identified included that 24-hour chart checks were done and weekly skin assessments were completed. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Citalopram and Ativan were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor reviewed the medication regimen review from 11/14/17 through 2/6/19. The surveyor was unable to locate any recommendations for gradual dose reductions for Celexa or Ativan. The last two physician progress notes dated 11/12/18 and 1/9/19 read in part Resident #12's mood as follows: Depression-mood is stable, continue on Celexa w/prn (with as needed). Ativan available for anxiety. The surveyor informed the administrative staff of the lack of monitoring/documentation for the use of Citalopram and Ativan to treat Resident #12's depression and anxiety on 2/7/19 at 3:52 p.m. The surveyor reviewed the facility policy titled Psychotropic Drug Use on 2/7/19. The policy read in part 2. Residents who receive psychotropic medications are required to receive gradual dose reductions and behavioral interventions, unless contraindicated, in an effort to discontinue use of the psychotropic medications. No further information was provided prior to the exit conference on 2/7/19. 6. The facility staff failed to ensure Resident #20 was free of unnecessary medications. Resident #20 was administered Escitalopram, Remeron, and Lorazepam without proper indications for use, monitoring and documentation of effects/side effects. The clinical record of Resident #20 was reviewed 2/5/19 through 2/7/19. Resident #20 was admitted to the facility 10/15/18 with diagnoses that included but not limited to adult failure to thrive, chronic depression, disruptive behavior, agitation, atrial fibrillation, fractured right femur neck, vascular dementia with behavioral disturbances, hypertension, and chronic diastolic heart failure. Resident #20's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 12/3/18 assessed the resident with a brief interview for mental status (BIMS) as 9/15. Resident #20 had no behavioral signs or symptoms, no signs or symptoms of delirium, or psychosis. Resident #20's February physician orders 2019 included Escitalopram 10 mg 1 tablet by mouth one time a day for depression (start date 12/11/18), Mirtazapine 7.5 mg 1 tablet by mouth one time a day at bedtime for poor appetite and Lorazepam gel 1 mg (milligram)/ml (milliliter) Apply topically every 6 hours as needed for psychosis/agitation/anxiety (start date 12/20/18). The surveyor reviewed Resident #20's current comprehensive care plan dated 12/3/18. Problem areas included one for mood state with long-term goal to have a peaceful sleep and approaches to use were to turn on my white noise machine at night and assure me that my roommate shares the room with me and that I am safe. Also identified as a problem area for mood state that the resident had symptoms of depression, a diagnosis of anxiety which is managed by daily medication. Approaches included watch me to make sure my depression does not get any worse, refer me to see the doctor to assess my mood, want my family to visit as much as possible, administer my medications as ordered, and provide me with emotional support as needed. Resident #20 also had an area dated 12/5/18 for psychotropic drug use with long-term goal to show a stable mood and socialize with others. Approaches included give me my medication as ordered, monitor me for side effects from my medication, and monitor me for changes in mood and/or behavior. The current comprehensive care plan did not identify specific targeted behaviors for the medications, long-term measurable goals or individualized approaches to care. The surveyor reviewed the undated behavior/intervention monitoring sheet for Ativan, Lexapro and Remeron. The behavioral symptoms coded were crying out and yelling out. The most recent episode of behavior occurred 1/8/19 and the resident received Ativan gel 0.5 mg (milligrams). The behavioral symptom code read that the resident had 5 episodes of yelling out, crying out, and delusions (no documentation of what the delusions were). Intervention codes read that 1 -1 visits, a snack was given, and resident was in bed yet Resident #20 received Ativan as an intervention. The physician note dated 1/14/19 read After adjustments with her medications, symptoms appear to have improved. Her level of agitation is under better control. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Citalopram and Ativan were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor informed the administrative staff of the lack of monitoring for the use of Escitalopram, Remeron, and Ativan to treat Resident #20's depression and anxiety on 2/7/19 at 3:52 p.m. The surveyor reviewed the facility policy titled Psychotropic Drug Use on 2/7/19. The policy read in part 2. Residents who receive psychotropic medications are required to receive gradual dose reductions and behavioral interventions, unless contraindicated, in an effort to discontinue use of the psychotropic medications. No further information was provided prior to the exit conference on 2/7/19. 7. The facility staff failed to ensure Resident #44 was free of unnecessary medications. Resident #44 was administered Valium, Escitalopram, and Quetiapine (Seroquel) without monitoring the use of the psychotropic medications effects/side effects and identified targeted behaviors. The clinical record of Resident #44 was reviewed 2/5/19 through 2/7/19. Resident #44 was admitted to the facility 1/18/18 with diagnoses that included but not limited to diabetes mellitus, urinary tract infection, constipation, abnormal weight loss, cerebrovascular accident (CVA), coronary artery disease (CAD), atrial fibrillation, hypertension, gastro esophageal reflux disease, and chronic obstructive pulmonary disease. Resident #44's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/24/19 assessed the resident with a BIMS (brief interview for mental status) as 13/15. Resident #44 was without signs or symptoms of delirium, behaviors affecting others or psychosis. Resident #44's February 2019 physician orders included orders for Valium 2 mg (milligrams) 1 tablet by mouth one time a day for vertigo start date 12/3/2018, Escitalopram 5 mg 1 tablet by mouth one time a day at bedtime for depression start date 1/7/2019 and Quetiapine (Seroquel) 25 mg (1/2 tablet) by mouth one time a day at bedtime for agitation d/t (due to psychosis) start date 4/13/2018. The surveyor reviewed the current comprehensive care plan for Resident #44 on 2/6/19. The person centered care plan identified a problem area for psychotropic drug use with long term goals of maintaining a stable mood and approaches to use give me my medication as ordered, monitor me for side effects from my medication, and monitor me for changes in mood and/or behavior. A second care plan identified an issue with mood long term goal was to be comfortable and satisfied and approaches included watch me to make sure my mood does not get any worse, have my family to visit as much as possible, especially my daughter and great granddaughter, and I enjoy playing Bingo and going to wine/cheese social. Please continue to remind me as needed about these events and encourage me to go. The current comprehensive care plan for Resident #44 did not have person centered targeted behaviors, measurable goals or individualized approaches to care. The undated behavior/intervention monitoring sheets had the following behavioral symptoms circled-crying out and yelling out. Resident #44 had documentation on 5/26/18, 9/28/18, and 11/3/18 of behaviors. On 5/26/18, yelling occurred x1. Intervention included 1-1 and activity, which improved outcome. On 7/28/18, yelling and screaming (screaming not circled as a behavioral symptom) occurred x1 but did not improve with 1-1 and speak with family; however, no more interventions were attempted. On 11/3/18, yelling and screaming occurred x2 and 1-1 intervention was tried with positive outcome. The clinical record had no documentation of what the incident was on 11/3/18. The clinical record revealed when Resident #44 was admitted to the facility 1/18/18, the resident was not administered any psychotropic medications. The February 2018 medication regimen review also indicated no high-risk medications prescribed to include psychotropic medication. Resident #44 was seen by the neurologist on 2/12/18 and prescribed Prozac 10 mg (milligrams) every day and Aricept 5mg every day for pseudo dementia with vascular cognitive impairment. The March 2018 medication regimen review indicated the resident had been prescribed Seroquel, Lexapro, and Aricept; however, the resident refused to take and the medications were discontinued. Seroquel was restarted in April 2018. A GDR was requested in August 2018 but the physician declined the GDR. Resident #44 was seen by the geriatric psychiatrist 11/19/18 and the consult read Patient's present tx (treatment) and nursing report reviewed. Continues to c/o (complain of) being dizzy. Very withdrawn. Keeps room dark. Makes frequent and negative remarks. No psychotic thoughts today (on Seroquel). The MDS progress notes by the social worker were reviewed. The 10/23/18 quarterly assessment read in part Resident #44 participated in the BIMS and mood assessment interviews on 10/22/18. She scored a 15/15 on the BIMS. No signs or symptoms of delirium present. Per the mood assessment she reported little interest in doing things and feeling down. Resident #44 is prescribed an antipsychotic for psychosis. She has rejected care by not allowing skin assessments to be completed. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Escitalopram, Diazepam, and Seroquel were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor informed the administrative staff of the absence of targeted behaviors, goals and desired outcomes for and the monitoring of effects/side effects with the use of Escitalopram, Diazepam, and Seroquel to treat Resident #44 on 2/7/19 at 3:52 p.m. The surveyor reviewed the facility policy titled Psychotropic Drug Use on 2/7/19. The policy read in part 2. Residents who receive psychotropic medications are required to receive gradual dose reductions and behavioral interventions, unless contraindicated, in an effort to discontinue use of the psychotropic medications. No further information was provided prior to the exit conference on 2/7/19. Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure that 7 of 16 residents were free from unnecessary medications (Resident #35, 31, 49, 15, 12, 20, and 44). The findings included: 1. For Resident #35, facility staff failed to ensure that psychotropic and antipsychotic medications were ordered only to address specific symptoms for which the resident was treated with antianxiety, antidepressant, and antipsychotic medications. Resident #35 was admitted to the facility on [DATE] with diagnoses including hypertension, dementia, and anxiety disorder. On the admission minimum data set assessment the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behavior symptoms. On the most recent quarterly minimum data set assessment with assessment reference date 1/8/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident scored 6/27 on the resident mood interview. During an interview on 2/5/19, the resident reported the only concern with care was not getting enough of the food, which was bad. Clinical record review on 2/7/19 revealed the resident was readmitted [DATE]. Medication orders included Buspar 5 mg three times per day for anxiety and seroquel 25 mg twice per day since admission and ativan as needed. The physician declined GDRs on both medications due to history of symptom instability. The surveyor was unable to locate documentation of symptoms being treated by the seroquel. There were no behavior or symptom tracking orders or nurse's notes referencing symptoms that might be considered signs of psychosis. The resident's nurse was unable to describe the symptoms for which the resident was taking antipsychotic medications. The surveyor spoke with the director of nursing (DON) about the issue. The DON was able to locate 2 Behavior Monitoring Sheets. One was blank except for documenting trazodone and lorazepam as medications the resident was receiving. No targeted symptoms were indicated. The second sheet indicated monitoring for 14-yelling and 16-c/o anxiety. The form indicated the resident c/o anxiety on 11/15/18 and received a 1-on-1 visit, rest in bed, and ativan and that the interventions were effective. No staff member was able to report the symptoms for which the antipsychotic medication seroquel was ordered. The Comprehensive Care plan for 1/24/16 through 10/19/17 did not document psychosis, psychotic disorder, or use of antipsychotic medication or symptoms of psychosis or delusion. The care plan initiated 10/19/17 documented I also have a history of psychosis for which I also take medication. The surveyor has been unable to locate any expression of symptoms for which the resident was taking an antipsychotic medication other than the physician's statement increased risk of psychiatric instability. There were no target symptoms or symptom abatement strategies in the care plan. The administrator and director of nursing were notified of the concern that psychotropic medications were not ordered to treat specific symptoms and that those symptoms were not documented in the clinical record and routinely monitored to ensure effectiveness of the medication in treating those symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to have a complete and accurate clinical record in regards to having no monitoring of behaviors while Resident #31 was receiving psychotropic medications. Resident was readmitted to the facility on [DATE] with the following diagnoses, but not limited to anemia, high blood pressure, Dementia, Parkinson's disease, depression and psychotic disorder. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/29/12, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15. Resident #31 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing. During the clinical record review on 2/6/19, the surveyor noted that Resident #31 was receiving the following physician ordered medications: Risperidone 0.25 mg (milligram) 1 tablet by mouth two times a day for psychosis. Zoloft 75 mg by mouth one time a day for depression. The surveyor performed a clinical record review on Resident #31 on 2/6 and 2/7/19. During this review, the surveyor noted that the resident was being given Zoloft daily for depression and Risperidone twice a day for psychosis. The surveyor reviewed the nurses' notes and MAR (Medication Administration Record) for the months of January and February 2019. There was no documentation of behaviors while receiving these medications. The surveyor notified the administrative team of the above documented findings on 2/6/19 at 4:05 pm in the conference room. The surveyor requested and received the facility's policy on behavioral monitoring. The policy titled Behaviors Identification and Interventions read in part .Residents with problematic behavioral symptoms will be promptly assessed and monitored by professional staff. Causative factors influencing behavioral will be identified. Management and appropriate behavioral interventions will be care planned, implemented and re-evaluated as changes occur . No further information was provided to the surveyor prior to the exit conference on 2/7/19 3. The facility staff failed to a complete and accurate clinical record in regards to having no monitoring of behaviors while Resident #49 was receiving psychotropic medications. Resident #49 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to atrial fibrillation, high blood pressure, stroke, dementia and anxiety. On the admission, MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/7/19 coded the resident as having a BIMS (Brief Interview for Mental Status) score of 5 out of a possible score of 15. Resident #49 was also coded as requiring extensive assistance of 1 staff member for dressing and limited assistance from 1 staff member for personal hygiene. The resident was also coded as being totally dependent on 1 staff member for bathing. On 2/6/19, the surveyor noted the following physician's order that included: Xanax 0.5 mg (milligram) 1 tablet by mouth two times a day for anxiety Seroquel 25 mg po (by mouth) at bedtime. The surveyor reviewed the clinical record for Resident #49 on 2/5/19 and 2/6/19.The surveyor also reviewed the comprehensive care plan for Resident #49. For Psychotropic drug use, the surveyor noted the following interventions: .Give me my medication as ordered. Monitor me for side effects from my medication. Monitor me for changes in mood and/or behavior . The surveyor notified the administrative team on 2/6/19 at 4:05 pm of the above documented findings. The surveyor requested and received the facility's policy on behavioral monitoring. The policy titled Behaviors Identification and Interventions read in part .Residents with problematic behavioral symptoms will be promptly assessed and monitored by professional staff. Causative factors influencing behavioral will be identified. Management and appropriate behavioral interventions will be care planned, implemented and re-evaluated as changes occur . No further information was provided to the surveyor prior to the exit conference on 2/7/19.4. The facility staff failed to document the symptoms for which Resident #15 was administered Remeron and Celexa. There was no ongoing behavior monitoring of a resident on two antidepressants. The clinical record of Resident #15 was reviewed 2/5/19 through 2/7/19. Resident #15 was admitted to the facility 9/13/17 with diagnoses that included but not limited to nausea with vomiting, generalized muscle weakness, gastroesophageal reflux disease with esophagitis, hypokalemia, iron deficient anemia, history of kidney stones, left hip surgery, chronic depression, and bilateral lower quadrant pain. Resident #15's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/27/18 assessed the resident with a BIMS (brief interview for mental status) as 15/15. There were no assessed signs of delirium, psychosis, or behaviors that affected others. Resident #15's February 2019 physician orders were reviewed. Resident #15 had orders and received Remeron 7.5 mg (milligrams) tablet one time a day at bedtime for decreased appetite/weight loss (start date 4/14/18) and Citalopram 20 mg tablet by mouth one time a day for depression (start date 4/14/18). Resident #15 had received both Remeron and Celexa since 4/14/18. The surveyor reviewed the current comprehensive care plan on 2/6/19. One Concern and Strength dated 9/10/18 read, I have a history of depression. I take medicine for this. My preference for care read 1. Give my med (medication) as ordered. 2. Monitor me for s/e (side effects) from my medicine. 3. Monitor me for changes in mood and or behavior. 4. I look forward to visits from my daughter. A second Concern and Strength dated 9/5/2018 read 1. Watch me to make sure my depression does not get any worse. 2. Administer my medications as ordered. 3. I would like my family to visit as much as possible. The current person centered care comprehensive care plan did not identify targeted behaviors, outcomes and goals for Citalopram (Celexa) or Remeron. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Citalopram and Remeron were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor reviewed the undated behavior/intervention monitoring tool for Resident #15. On the tool, crying out and c/o (complaints of) depression were circled under the behavioral symptoms codes. However, there was no evidence of crying out or depression documented on the tool. The surveyor reviewed the January and February 2019 interdisciplinary progress notes and found no documented behaviors. The surveyor interviewed Resident #15 on 2/5/19 at 2:56 p.m. When asked about mood, the resident stated, I am always happy. The surveyor informed the administrative staff of the lack of documentation of the behavior monitoring and the effects/side effects with the use of Citalopram and Remeron to treat Resident #15 on 2/7/19 at 3:52 p.m. The director of nursing stated the facility only documented behavior by exception. The surveyor requested the facility policy on behavior documentation. The facility policy titled Behavior Identification and Intervention was reviewed 2/7/19. The policy read in part Assessment of identified behaviors will be documented in (but not limited to) nursing notes, behavior tracking forms and social service progress notes to help clarify the underlying cause of the behavior and help develop effective management interventions. No further information was provided prior to the exit conference on 2/7/19. 5. The facility staff failed to document the symptoms for which the Citalopram and Ativan were used to treat Resident #12's behaviors. There was no ongoing behavior monitoring of a resident administered an antidepressant and antianxiety. The clinical record of Resident #12 was reviewed 2/5/19 through 2/7/19. Resident #12 was admitted to the facility 10/1/16 and readmitted [DATE] with diagnoses that included but not limited to urinary tract infection, diabetes, dehydration, weakness, constipation, abnormal weight loss, atrial fibrillation, rheumatoid arthritis, depression, chronic pain syndrome, adult failure to thrive, and osteoporosis. Resident #12's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/9/18 assessed the resident with a BIMS (brief interview for mental status) as 11/15. The resident had no signs or symptoms of delirium, psychosis or behaviors that affected others. Resident #12's February 2019 physician orders included Citalopram 10 mg (milligrams) 1 tablet by mouth one time a day in the morning for depression (start date 11/8/18) and Lorazepam 0.5 mg 1 tablet by mouth one time a day at bedtime for anxiety (start date 10/8/18). Resident #12 received both Citalopram and Lorazepam since November 2018. Resident #12's current comprehensive care plan dated 8/14/18 had the following My Concerns and my strengths for 8/14/18. I have a history of anxiety and depression. I take medicine for this. My preference for care 1. Give me my medication as ordered. 2. Monitor me for s/e (side effects) from my medications 3. Monitor me for changes in mood and /or behaviors. A second I Care Plan dated 8/9/18 read I have a diagnosis of depression and anxiety. Occasionally I have trouble concentrating. 1. Observe me to make sure my mood remains stable and my daily needs are met. 2. I want my family to visit as much as possible. 3. I want to socialize with others and participate in the activities of my choice. 4. Administer my medications as ordered. The current comprehensive care plan did not identify person centered targeted behaviors, goals, and outcomes for the use of Lorazepam (Ativan) and Citalopram. The undated behavior/intervention monitoring tools were circled for crying out and c/o (complains of) anxiety as behavior symptoms codes. The behavior/intervention monitoring sheet did not have any documentation of Resident #12 having crying out or c/o anxiety. There was no documentation to support the use of both Lorazepam and Citalopram (Celexa). The surveyor reviewed the quarterly MDS progress notes. The social services quarterly note dated 11/12/18 read Resident #12 participated in the BIMS mood assessment interview on 11/7/2018. Resident #12 scored an 11/15 on the BIMS; she could not recall two words. No signs or symptoms of delirium present. Per the mood assessment, Resident #12 reported feeling tired. Resident #12 is prescribed an antidepressant and anti-anxiety medication with no adverse effects noted. No behaviors noted. The surveyor reviewed the interdisciplinary progress notes from December 2018 through 2/6/19 and found no evidence to support the use of Celexa and Ativan. Documentation identified included that 24-hour chart checks were done and weekly skin assessments were completed. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Citalopram and Ativan were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor informed the administrative staff of the lack of monitoring/documentation for the use of Citalopram and Ativan to treat Resident #12's depression and anxiety on 2/7/19 at 3:52 p.m. The director of nursing stated the facility documents behaviors by exception. The facility policy titled Behavior Identification and Intervention was reviewed 2/7/19. The policy read in part Assessment of identified behaviors will be documented in (but not limited to) nursing notes, behavior tracking forms and social service progress notes to help clarify the underlying cause of the behavior and help develop effective management interventions. No further information was provided prior to the exit conference on 2/7/19. 6. The facility staff failed to document the symptoms for which Resident #20 was administered Escitalopram, Remeron, and Lorazepam. There was no ongoing behavior monitoring and documentation of behaviors for a resident receiving two antidepressants and an antianxiety medication. The clinical record of Resident #20 was reviewed 2/5/19 through 2/7/19. Resident #20 was admitted to the facility 10/15/18 with diagnoses that included but not limited to adult failure to thrive, chronic depression, disruptive behavior, agitation, atrial fibrillation, fractured right femur neck, vascular dementia with behavioral disturbances, hypertension, and chronic diastolic heart failure. Resident #20's significant change in assessment minimum data set (MDS) with an assessment reference date (ARD) of 12/3/18 assessed the resident with a brief interview for mental status (BIMS) as 9/15. Resident #20 had no behavioral signs or symptoms, no signs or symptoms of delirium, or psychosis. Resident #20's February physician orders 2019 included Escitalopram 10 mg 1 tablet by mouth one time a day for depression (start date 12/11/18), Mirtazapine 7.5 mg 1 tablet by mouth one time a day at bedtime for poor appetite and Lorazepam gel 1 mg (milligram)/ml (milliliter) Apply topically every 6 hours as needed for psychosis/agitation/anxiety (start date 12/20/18). The surveyor reviewed Resident #20's current comprehensive care plan dated 12/3/18. Problem areas included one for mood state with long-term goal to have a peaceful sleep and approaches to use were to turn on my white noise machine at night and assure me that my roommate shares the room with me and that I am safe. Also identified as a problem area for mood state that the resident had symptoms of depression, a diagnosis of anxiety which is managed by daily medication. Approaches included watch me to make sure my depression does not get any worse, refer me to see the doctor to assess my mood, want my family to visit as much as possible, administer my medications as ordered, and provide me with emotional support as needed. Resident #20 also had an area dated 12/5/18 for psychotropic drug use with long-term goal to show a stable mood and socialize with others. Approaches included give me my medication as ordered, monitor me for side effects from my medication, and monitor me for changes in mood and/or behavior. The current comprehensive care plan did not identify specific targeted behaviors for the medications, long-term measurable goals or individualized approaches to care. The surveyor reviewed the undated behavior/intervention monitoring sheet for Ativan, Lexapro and Remeron. The behavioral symptoms coded were crying out and yelling out. The most recent episode of behavior occurred 1/8/19 and the resident received Ativan gel 0.5 mg (milligrams). The behavioral symptom code read that the resident had 5 episodes of yelling out, crying out, and delusions (no documentation of what the delusions were). Intervention codes read that 1 -1 visits, a snack was given, and resident was in bed yet Resident #20 received Ativan as an intervention. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Citalopram and Ativan were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor informed the administrative staff of the lack of documentation of the behavior monitoring and the effects/side effects with the use of Escitalopram, Ativan and Remeron to treat Resident #20 on 2/7/19 at 3:52 p.m. The director of nursing stated the facility only documented behavior by exception. The surveyor requested the facility policy on behavior documentation. The facility policy titled Behavior Identification and Intervention was reviewed 2/7/19. The policy read in part Assessment of identified behaviors will be documented in (but not limited to) nursing notes, behavior tracking forms and social service progress notes to help clarify the underlying cause of the behavior and help develop effective management interventions. No further information was provided prior to the exit conference on 2/7/19. 7. The facility staff failed to document the symptoms for which Resident #44 was administered Valium, Escitalopram, and Quetiapine (Seroquel). There was no ongoing behavior monitoring of a resident on an antidepressant, an antipsychotic and an antianxiety medication. The clinical record of Resident #44 was reviewed 2/5/19 through 2/7/19. Resident #44 was admitted to the facility 1/18/18 with diagnoses that included but not limited to diabetes mellitus, urinary tract infection, constipation, abnormal weight loss, cerebrovascular accident (CVA), coronary artery disease (CAD), atrial fibrillation, hypertension, gastro esophageal reflux disease, and chronic obstructive pulmonary disease. Resident #44's annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 1/24/19 assessed the resident with a BIMS (brief interview for mental status) as 13/15. Resident #44 was without signs or symptoms of delirium, behaviors affecting others or psychosis. Resident #44's February 2019 physician orders included orders for Valium 2 mg (milligrams) 1 tablet by mouth one time a day for vertigo start date 12/3/2018, Escitalopram 5 mg 1 tablet by mouth one time a day at bedtime for depression start date 1/7/2019 and Quetiapine (Seroquel) 25 mg (1/2 tablet) by mouth one time a day at bedtime for agitation d/t (due to psychosis) start date 4/13/2018. The surveyor reviewed the current comprehensive care plan for Resident #44 on 2/6/19. The person centered care plan identified a problem area for psychotropic drug use with long term goals of maintaining a stable mood and approaches to use give me my medication as ordered, monitor me for side effects from my medication, and monitor me for changes in mood and/or behavior. A second care plan identified an issue with mood long term goal was to be comfortable and satisfied and approaches included watch me to make sure my mood does not get any worse, have my family to visit as much as possible, especially my daughter and great granddaughter, and I enjoy playing Bingo and going to wine/cheese social. Please continue to remind me as needed about these events and encourage me to go. The current comprehensive care plan for Resident #44 did not have person centered targeted behaviors, measurable goals or individualized approaches to care. The undated behavior/intervention monitoring sheets had the following behavioral symptoms circled-crying out and yelling out. Resident #44 had documentation on 5/26/18, 9/28/18, and 11/3/18 of behaviors. On 5/26/18, yelling occurred x1. Intervention included 1-1 and activity, which improved outcome. On 7/28/18, yelling and screaming (screaming not circled as a behavioral symptom) occurred x1 but did not improve with 1-1 and speak with family; however, no more interventions were attempted. On 11/3/18, yelling and screaming occurred x2 and 1-1 intervention was tried with positive outcome. The clinical record had no documentation of what the incident was on 11/3/18. The surveyor interviewed both minimum data set (MDS) assessment registered nurses on 2/7/19 at 11:33 a.m. Both reviewed the current care plan and when the surveyor asked what behaviors the Escitalopram, Diazepam, and Seroquel were targeting, the MDS staff agreed there were no targeted behaviors identified. The surveyor informed the administrative staff of the lack of ongoing behavior monitoring documentation and no documentation of effects/side effects with the use of Escitalopram, Diazepam, and Seroquel to treat Resident #44 on 2/7/19 at 3:52 p.m. The facility policy titled Behavior Identification and Intervention was reviewed 2/7/19. The policy read in part Assessment of identified behaviors will be documented in (but not limited to) nursing notes, behavior tracking forms and social service progress notes to help clarify the underlying cause of the behavior and help develop effective management interventions. No further information was provided prior to the exit conference on 2/7/19. The facility staff failed to maintain a complete and accurate clinical record for 7 of 16 residents in the survey sample (Residents #35, 31, 49, 15, 12, 20, and 44). The findings included: 1. For Resident #35, facility staff failed to ensure that psychotropic and antipsychotic medications were ordered only to address specific symptoms for which the resident was treated with antianxiety, antidepressant, and antipsychotic medications. Resident #35 was admitted to the facility on [DATE] with diagnoses including hypertension, dementia, and anxiety disorder. On the admission minimum data set assessment the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behavior symptoms. On the most recent quarterly minimum data set assessment with assessment reference date 1/8/19, the resident scored 15/15 on the brief interview for mental status and was assessed as without symptoms of delirium, psychosis, or behaviors affecting care. The resident scored 6/27 on the resident mood interview. During an interview on 2/5/19, the resident reported the only concern with care was not getting enough of the food, which was bad. Clinical record review on 2/7/19 revealed the resident was readmitted [DATE]. Medication orders included Buspar 5 mg three times per day for anxiety and seroquel 25 mg twice per day since admission and ativan as needed. The physician declined GDRs on both medications due to history of symptom instability. The surveyor was unable to locate documentation of symptoms being treated by the seroquel. There were no behavior or symptom tracking orders or nurse's notes referencing symptoms that might be considered signs of psychosis. The resident's nurse was unable to describe the symptoms for which the resident was taking antipsychotic medications. The surveyor spoke with the director of nursing (DON) about the issue. The DON was able to locate 2 Behavior Monitoring Sheets. One was blank except for documenting trazodone and lorazepam as medications the resident was receiving. No targeted symptoms were indicated. The second sheet indicated monitoring for 14-yelling and 16-c/o anxiety. The form indicated the resident c/o anxiety on 11/15/18 and received a 1-on-1 visit, rest in bed, and ativan and that the interventions were effective. No staff member was able to report the symptoms for which the antipsychotic medication seroquel was ordered. The Comprehensive Care plan for 1/24/16 through 10/19/17 did not document psychosis, psychotic disorder, or use of antipsychotic medication or symptoms of psychosis or delusion. The care plan initiated 10/19/17 documented I also have a history of psychosis for which I also take medication. The surveyor has been unable to locate any expression of symptoms for which the resident was taking an antipsychotic medication other than the physician's statement increased risk of psychiatric instability. There were no target symptoms or symptom abatement strategies in the care plan. Physician progress note on 9/26/18 listed under history continues to have intermittent paranoia and anxiety. No symptoms of paranoia were documented in the resident's nursing notes or behavior monitoring sheets. Only one instance of reported anxiety was listed in the resident's nursing notes or behavior monitoring sheet. The administrator and director of nursing were notified of the concern that symptoms were not documented in the clinical record and routinely monitored to ensure effectiveness of the medication in treating those symptoms.

Based on observation, staff interview , resident interview, clinical record review, facility document review, and review of the prior survey report, facility staff failed to develop and implement appropriate plans of action to correct identified quality deficiencies in the area of comprehensive care planning and unnecessary medication (monitoring use of psychotropic medication medications). The facility's QA (Quality Assurance) plan failed to correct two deficiencies cited during the annual certification survey conducted 10/24/2017 through 10/26/17. The problem cited still existed for the resident cited in the prior survey and extends to all psychotropic medications and for 6 additional residents in the sample. Surveyors found general lack of documentation of symptoms and behaviors either in the nursing notes or in behavior monitoring sheets. During the course of the survey, surveyors identified a pattern with a potential for harm level deficient practice in the area of comprehensive care planning related to the use of psychotropic medications and a pattern with a potential for harm level deficient practice in the area of monitoring target behaviors in the use of psychotropic medications. Review of the survey report from the prior survey revealed that the facility had been cited for deficient practice in care planning at a level E (pattern of deficient practice with potential for harm). One of the residents affected by the original deficient practice is in the sample (Resident #35; Resident #6 in the original survey) and continues to be affected by the deficient practice. Review of the survey report from the prior survey revealed that the facility had been cited for deficient practice in monitoring target behaviors in the use of psychotropic medications at a level D (isolated incidents of deficient practice with potential for harm). The resident affected by the original deficient practice is in the sample (Resident #35; Resident #6 in the original survey) and continues to be affected by the deficient practice. Surveyors found this deficient practice affected 6 additional residents in the current survey sample, increasing scope to a pattern. Review of the prior plan of correction revealed the facility had stated that the deficient practices in care planning and monitoring targeted behaviors could not be corrected for the resident (Resident #6 in the original survey) and that no plan would be put in place to ensure that residents receiving psychotropic medications would have care plans for their use or that targeted behavior monitoring would be performed by nursing staff. The administrator and director of nursing were notified during a summary meeting on 2/7/19 of the failure of the Quality Assurance program to correct identified deficient practices.