**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure that 1 (R8) of 5 residents drug regimen was free from unnecessary drugs. R8 was prescribed Risperidone for verbal and physical aggression. The facility failed to adequately monitor R8's response to Risperidone and failed to recognize adverse consequences of Risperidone therapy including lethargy, decreased Activities of Daily Living (ADL) function and decreased oral intake. The facility failed to adjust R8's Risperidone when R8 presented with adverse consequences. R8 was administered Risperidone (Antipsychotic) daily starting on 6/22/25 following two days of intermittent verbal and physical aggression. Following initiation of Risperidone, R8 presented with lethargy, decreases in activity participation, ADL abilities and oral intake. The facility continued the Risperidone without evidence of monitoring for adverse consequences or side effects related to the initiation of the antipsychotic. The Risperidone was not reduced in attempts to see if the Risperidone was the causative factor for R8's acute decline. R8 was observed multiple times to be somnolent, lethargic, and non-interactive with staff during survey.The facility's failure to ensure R8 drug regime was free from unnecessary drugs created a finding of Immediate Jeopardy, beginning on 7/10/25. The NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were informed of the Immediate Jeopardy on 8/7/25 at 3:49 PM. The immediate jeopardy was removed on 8/7/25; however, the deficient practice continues at a scope/severity level of D (Potential for harm/Isolated) as the facility continues to implement its action plan.Findings include:The facility's policy and procedure entitled, Restraint Free Environment, dated 9/22/22, states, in part: Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Chemical Restraint refers to any medication that is used for discipline or staff convenience, and not required to treat medical symptoms. Convenience refers to any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. Medical Symptom refers to an indication or characteristic of a physical or psychological condition. 5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: a. How the use of restraints would treat the medical symptom. b. The length of time the restraint is anticipated to be used to treat the medical symptom. c. The direct monitoring and supervision that will be provided during use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being.The facility policy entitled, Use of Psychotropic Medication(s), dated 4/27/25, states in part: Policy: It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. For psychotropic medications, without documentation in the record explaining that the practitioner has determined that other treatments have been deemed clinically contraindicated, the indication for use is inadequate. Also, adequate indication for use means that the medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review of articles that are published in medical and/or pharmacy journals. Adverse consequence is a broad term referring to unwanted, unintended, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics. 2. Psychotropic medications are to be used only when a practitioner determines that the medication(s) is appropriate to treat a resident's specific, diagnosed, and documented condition and the medication(s) is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 6. Non-pharmacological approaches should be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. 7. The resident's medical record shall include documentation of this evaluation and the rationale for chosen treatment options. 14. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's monthly medication regimen review, c. During MDS (Minimum Data Set) review, and d. In accordance with nurse assessment and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications and the resident's comprehensive plan of care. 15. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record.R8 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations (movement disorder caused by neuron degeneration that affects the nervous system), weakness, type 2 diabetes, mild cognitive impairment of uncertain or unknown etiology, congestive heart failure (heart is unable to pump blood effectively leading to fluid buildup in the lungs and legs), and adult failure to thrive.R8's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 5/9/25 indicates R8 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating moderate cognitive impairment. Section GG indicates R8 was independent with eating, required supervision/touching assistance with oral hygiene, and required partial/moderate assistance with rolling left/right. Section GG also indicates R8 required substantial/maximal assistance with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, moving from sitting to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet.(Of note: R8's previous MDS data, dated 3/27/25 indicates R8 had improved from not being able to ambulate previously to now being able to ambulate 10 feet.)R8's Comprehensive Care Plan states, in part:Focus: Enjoys activities such as (reading newspapers and magazines, music, pets/animals, outdoors). Date Initiated: 3/22/25.Goals: Will actively participate in independent activities of choice. Date Initiated: 3/22/25. Target Date: 10/9/25. Will participate in activities that promote socialization with peers consistent with likes and interests such as: eating in the dining room, music groups, Bingo, and other games as he allows. Date Initiated: 3/22/25. Target Date: 10/9/25. Will participate in independent activities of choice such as: watching TV in his room, visiting with family. Date Initiated: 3/22/25. Target Date: 10/9/25.Interventions:Assist in planning and/or encourage to plan own leisure time activities. Date Initiated: 3/22/25.Assist to transport to and from activities of choice. Date Initiated: 3/22/25.Encourage participation in group activities of interest. Date Initiated: 3/22/25.Offer activities consistent with resident's known interest, physical and intellectual capabilities such as: outdoor activities, Bingo, Music Groups. Date Initiated: 3/22/25.Offer/supply large print materials. Date Initiated: 3/22/25.Provide supplies/materials for leisure activities as needed/requested. Date Initiated: 3/22/25.The Resident's preferred activities are: Animals/Pets (Dogs, Visiting Resident Birds), Music (Oldies, Rock & Roll, Country, Hymns, Music Entertainment), Reading (Our Wisconsin, etc., Variety Newspapers), Games/Cards (Bingo Euchre), TV (Gameshow Network, Old Shows, Friends), Current Events (News/Weather on TV, Variety Newspapers), Sitting Outdoors/Fresh Air (Weather Permitting), Socializing/reminiscing With Others, Family Centered Functions. Date Initiated: 7/14/25. Focus: The resident has limited physical mobility. Date Initiated: 3/17/254. Revision on: 3/17/25.Goal: The resident will increase level of mobility through the next review date. Date Initiated: 3/17/25. Target Date: 10/9/25.Interventions:AMBULATION/LOCOMOTION - ASSIST - ONE. Date Initiated: 3/17/25. Revision on: 3/27/25.BED MOBILITY - ASSIST - ONE. Date Initiated: 3/17/25. Revision on: 3/17/25.TRANSFER - ASSIST - 2, Hoyer, lg (large) sling risk vs benefit completed on resident choosing to use different sling size than recommended by manufacturer. Date initiated: 7/2/25. Revision on: 7/11/25. Focus: At risk for behavior symptoms r/t (related to): (specify) end stage disease (Parkinson's). Date Initiated: 6/21/25. Revision on: 6/24/25.Goal: Will accept care and medications as prescribed. Date Initiated: 6/24/25. Target Date: 10/9/25. Maintain involvement with ADL (Activities of Daily Living) performance and social activities. Date Initiated: 6/21/25. Revision on: 6/24/25. Target Date: 10/9/25.Interventions:Administer medications per physician order. Date Initiated: 6/21/25. Revision on: 6/26/25.Behavior 1 aggressive. Intervention #1: redirection. Intervention #2: another staff member. Intervention #3: try later. Date Initiated: 6/21/25. Revision on: 6/26/25.Staff to take vitals as resident allows. Date Initiated: 6/25/26. Revision on: 6/26/25. Focus: Verbal/physical agitation/aggression (specify actions) r/t: cognitive impairment. Date Initiated: 7/3/25. Revision on: 7/3/25.Interventions:Administer medications per physician orders. Date Initiated: 7/3/25.Approach slowly and slightly to the side. Date Initiated: 7/3/25.Give resident clear, concise explanation of anything about to occur. Date Initiated: 7/3/25.If strategies are not working, leave (if safe to do so) and reapproach later. Date Initiated: 7/3/25.Involve in 1:1 recreational activity. Date Initiated: 7/3/25. Focus: The resident is at risk for behavioral problem. Resident had exhibited inappropriate sexual behavior such as grabbing, touching, verbal statements r/t: mild cognitive impairment. Date Initiated: 3/17/25. Revision on: 6/16/25.Goal: The resident will have no evidence of behavior problems by review date. Date Initiated: 3/17/25. Revision on: 3/17/25. Target Date: 10/9/25.Interventions:Anticipate and meet the resident's needs. Date Initiated: 3/17/25.Distract if able. Date Initiated: 6/16/25.Encourage resident to express feelings. Date Initiated: 3/17/25.Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 6/16/25.Praise resident. Date Initiated: 6/16/25.Redirect as needed. Date Initiated: 6/16/25.Resident may not be able to remember passcode to phone due to DX (Diagnosis) of dementia. Passcode is [Resident's Passcode]. Date Initiated: 4/6/25. Focus: At risk for adverse effects r/t: use of antipsychotic medication. Date Initiated: 6/26/25. Revision on: 6/26/25.Goal: . To show minimal/no side effects of medications taken. Date Initiated: 6/26/25. Target Date: 10/9/25.Interventions:Antipsychotic Medication: Report adverse effects such as dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea, vomiting, lethargy, drooling, EPS (Extrapyramidal Symptoms; tremors, increased agitation, restlessness, involuntary movement of mouth or tongue). Date Initiated: 6/26/25.AIMS (Abnormal Involuntary Movement Scale) testing per facility guidelines (upon admission, initiation of, change of, every 6 months, and PRN). Date Initiated: 6/26/25.Non-Pharm (Non-pharmacological) Interventions for behaviors:1. Address in a calm manner2. Attempt to orientate to place and time3. Allow resident to express feelings or frustrations and provide reassurance as needed4. Provide assistance as needed5. Family visits6. Offer activities of choice7. Provide emotional support to resident as needed8. Offer to close door and curtains to facilitate sleep. Date Initiated: 6/26/25.TARGET BEHAVIOR 1: Physically aggressive behavior (pinching, kicking, biting or hitting) Intervention #1: ensure safety leave, try again later. Intervention #2: try using different staff. Interventions #3: diversion, engage in conversation about his dog, bingo, music, therapy dog ([Name].). Date Initiated: 6/26/25. Revision on: 6/26/25.TARGET BEHAVIOR 2: Verbally aggressive or sexually inappropriate language. Intervention #1: Remain calm, don't react. Intervention #2: Try cares at a later time. Intervention #3: Try other staff. Date Initiated: 6/26/25. Revision on: 6/26/25. Focus: Cognitive loss as evidenced by confusion and agitation r/t (related to): Parkinson's disease. Date Initiated: 7/3/25. Revision on: 7/3/25.Interventions:Allow adequate time to respond. Do not rush or supply words. Date Initiated: 7/3/25.Approach/speak in a calm, positive/reassuring manner. Date Initiated: 7/3/25.Attempt to provide consistent routines/caregivers. Date Initiated: 7/3/25.Encourage low stress activities such as music, small group activities. Date Initiated: 7/3/25.Identify self when speaking to resident. Date Initiated: 7/3/25.Invite to participate in activities such as trivia, reminiscence, current events/newspapers. Date Initiated: 7/3/25.R8's Weight Documentation indicates R8 weighed 194 lbs. on 5/19/25.R8's Behavior Monitoring Documentation from May 2025 indicates R8 exhibited behaviors such as: yelling/screaming, abusive language, threatening behavior, rejection of care, pushing, and sexually inappropriate behavior on 6 out of 93 shifts in May 2025.A physician note dated 6/5/25 at 5:22 PM, written by DO O (Doctor of Osteopathic Medicine), states, in part: . Nursing reports that he has not had any essentially aggressive behaviors since medications changes were made. Patient has [sic] had episodes of confusion which has resulted in activation of his POA (Power of Attorney) in April. He has not tried leaving the facility within the last 6 weeks.R8's Weight Documentation indicates R8 weighed 190.5 on 6/16/25.On 6/17/25 at 21:53 (9:53 PM), a Behavior Note is written that states: Resident was very aggressive towards staff during cares, found walking in hall and unable to redirect, staff assisted as resident would allow with wheelchair to follow. Resident refused gait belt and became aggressive when staff tried. Resident did calm some and was able to eat dinner in dining room without incident. Resident went back to room and was watching television and seemed to be back to his baseline. Resident was later found to be exiting the building through the patio door. Resident was in sight by writer before exiting the building. Resident was walking with walker unassisted, appropriate clothing and footwear, staff assisted resident to wheelchair, and he calmly came back into facility. No other incidents this shift.On 6/19/25 at 16:21 (4:21 PM), a Psychosocial Assessment is completed that indicates R8 has no psychosocial symptoms related to communication or cognitive status. The assessment also states, in part: . 1. Mood or Behavior concerns since last assessment: Increased anger and inappropriate sexual comments with increased dementia and confusion. Additional Comments: POA-HC (Power of Attorney- Healthcare) will be asked to provide consent for psych (psychiatric) consult. D. Psychosocial status: 1. Check all those that apply: 1. Difficulty accepting placement and circumstances. 5. Participates in Living Center Programs 6. Pursues Indepedendent Activities. 7. Maintains Supportive Relationships. 1b. Comments: [Resident Name] doesn't understand why he can't go home and have his wife care for him. She is no longer able. He attends many activities including euchre, bingo, daily music, and special events. [Resident Name] continues to maintain relationship with his sister, brother, sister-in-law, and his wife.On 6/20/25 at 08:23 AM, a Quarterly Activity Participation Review is completed that indicates R8 participates in facility led small group activities daily, large group activities weekly, and 1:1s daily. The review also indicates R8 participates in daily independent activities and his favorite activities include cognitive (trivia, discussion, reading, word puzzles), entertainment (television, music, movies, visiting groups), games (board games, bingo, cards, video games, tablets), and social parties (parties, visiting w/ friends & family, social media, etc.).On 6/20/25 at 07:42 AM, an eINTERACT SBAR (Situation, Background, Assessment, Recommendations) Summary for Providers Note is written that states, in part: . Mental Status Evaluation: Increased confusion (e.g. disorientation) New or worsened delusions or hallucinations. Behavioral Status Evaluation: Verbal aggression Personality change. Nursing observations, evaluation, and recommendations are: resident has increased agitation and behaviors. Primary Care Provider Feedback:. monitor per policy update with further changes.On 6/20/25 at 14:07 (2:07 PM), a Clinical Follow Up Note is written that states: Resident is on follow up for: change in condition for increased agitation and behaviors. The current status is resident refused to allow nurses to get vitals even after several attempts. Resident is agitated and exit seeking, one on one at this time. monitor per policy.On 6/20/25 at 21:23 (9:23 PM) a Behavior Note is written that states: Resident is very aggressive towards staff tonight hitting grabbing yelling kicking and making inappropriate sexual comments very difficult to redirect.On 6/20/25 at 22:11 (10:11 PM) a Clinical Follow Up Note is written that states: Resident is on follow up for: change in condition for increased behaviors and agitation. The current status is resident is resting in wheel chair; has been one on one with DON (Director of Nursing) this shift due to exit seeking and behaviors. Resident hit, kicked, pinched staff swore at them. Resident given a snack; music played. Calm at this time. monitor per policy.On 6/20/25 at 22:45 (10:45 PM) a Behavior Note is written that states: this shift, resident has been agitated, aggressive, hitting, kicking, spitting on staff, redirection, one on one, music, snack, activity all provided. Resident had attempted to remove his shirt himself, would not allow staff to help, resident had shirt stuck around his wrists and hand, resident kept trying to pull shirt off and this may cause bruising.On 6/21/25 at 03:57 AM, a Behavior Note is written that states: Resident was restless and crawling out of bed tonight. Resident was incontinent of urine and changed both times. Resident was grabbing and was sexually inappropriate while staff was performing hygiene cares. Resident was dressed in a brief; gown and transferred to a w/c (wheelchair) and brought up front by the nurse's station to be under direct staff supervision.On 6/21/25 at 06:03 AM, a Clinical Follow Up Note is written that states: The current status is resident slid out of bed, head and chest on bed, legs on floor, kneeling. resident alert and confused at baseline. resident has been on a change in condition for increased agitation and behaviors. resident is calm at this time, sitting in wheelchair asking when it is time to go home. monitor per policy.On 6/21/25 at 07:14 AM, a Clinical Follow Up Note is written that states: Resident is on follow up for: resident on change in condition for increased behaviors and agitation. The current status is resident is hallucinating, hitting, kicking, pinching, swearing at staff. Resident is being sent to [Facility Name] ER (Emergency Room) for this change. sent to ER.On 6/21/25 at 08:10 AM, a Nursing Note is written that states: resident has been hallucinating, aggressive. This nurse called and got an order to eval (evaluate) and treat at [Facility Name] ER. resident POA (Power of Attorney) approved transfer. This nurse called sheriff dept (department) and requested [Emergency Medical Service Name] for transfer to [Facility Name]. [Emergency Medical Service Name] came, and resident was combative with them as well. resident hitting, kicking, spitting, swearing. resident alert but confused, does have diagnosis for mild cognitive impairment. resident was safely secured to cot and taken by EMS (Emergency Medical Services).On 6/21/25 at 10:41 AM, a Clinical Note is written that states: Resident is on follow up for: resident on change in condition for increased behaviors and agitation. The current status is Resident is currently being returned to facility by ambulance after being evaluated by [Facility Name], resident will be returning to facility with new orders for Risperidone Q (every) day. Continue to monitor and update MD as needed.R8's Behavior Monitoring Documentation from June 2025 indicates R8 exhibited behaviors such as: yelling/screaming, abusive language, threatening behavior, rejection of care, pushing, grabbing, and sexually inappropriate behavior on 22 out of 93 shifts in June 2025, with 6 of these shifts occurring between 6/17/25 and 6/21/25.R8's Physician Orders for June 2025 state, in part:Carbidopa-Levodopa (Treats Parkinson's disease by Oral Tablet 25-250 MG (Carbidopa Levodopa) Give 1 tablet by mouth three times a day related to PARKINSONS DISEASE WITHOUT DYSKENESIA, WITHOUT MENTIONS OF FLUCTUATIONS. Start Date: 4/5/25. D/C (Discontinue) Date: 6/24/25.Risperidone Oral Tablet 0.5 MG (Milligrams) (Risperidone) Give 1 tablet by mouth one time a day for Agitation. Start date: 6/22/25. Active Order.Risperidone Oral Tablet 0.25 MG (Risperidone) Give 1 tablet by mouth every 24 hours as needed for agitation. Give at HS (Bedtime) if needed for agitation. Start date: 6/21/25. D/C date: 7/7/25.On 6/21/25 at 14:00 (2:00 PM), a Behavior Note is written that states: Resident is attempting to pack his belongings, states he is leaving because staff stole his furniture. Nurse reassured resident that all of his furniture is still in his room. Resident began to get upset but was redirectable.On 6/21/25 at 15:44 (3:44 PM), a Nursing Note is written that states, in part: Narrative: resident is hitting, kicking, pinching, swearing at staff. resident is one to one at this time. POA gave verbal consent for risperidone. attempted to listen to music, activity, redirection, unsuccessful nurse is going up and down hall with resident. one on one.On 6/21/25 at 16:10 (4:10 PM), a Communication with the Emergency Dept of the hospital Note was written that states: Dr. [Name] at [Facility Name] ER gave a onetime order for a 0.5 risperidone by mouth.On 6/21/25 at 18:31 (6:31 PM), a Clinical Follow Up Note is written that states: Resident is on follow up for: Resident was sent to ER after 2 falls overnight and increased physical and aggressive behaviors. The current status is Resident started on Risperidone scheduled and PRN dose. Resident was aggressive with staff prior to dinner. Hitting, kicking at, verbally aggressive, inappropriate sexual comments. Continuous attempts to stand without staff assist or locking breaks [sic] on wheelchair. Staff was 1:1 with resident due to statements of wanting to leave building. ER contacted and one time dose of Risperidone given. Resident ate dinner and is in wheelchair. Mood has improved; aggressive behavior has decreased.On 6/21/25 at 21:30 (9:30 PM), an Administration Note is written that states, in part: risperidone Oral Tablet 0.25 MG. PRN Administration was: Ineffective. Resident continue with aggression but is improving. R8's Meal Intake Documentation indicates:Between 6/1/25 and 6/21/25, R8 ate 61 meals over 21 days, with 2 meals either refused or R8 was not available. R8 consumed 76-100% of 53 of meals, 51-75% of 6 of meals, 26-50% of 1 of meals, 0-25% of 1 of meal.(Of note: This documentation indicates R8 ate 76-100% of his meal for 87% of his meals eaten.)R8's Fluid Intake Documentation indicates:Between 6/1/25 and 6/21/25, R8 consumed an average daily fluid intake for this time period of 2,091 mL/day.R8's Activity Documentation Indicates:Between 6/1/25 and 6/21/25, R8 participated in 23 activities over 21 days. 10 were 1:1 activities with staff, 4 were independent activities initiated by staff but completed without staff, 8 were group activities, and 1 activity R8 was observed to be participating in, but did not include any staff involvement or participation. R8 had active participation in 20 of these activities, passive participation in 1 activity, and observation only in 2 activities.(Of note: This documentation indicates R8 had active participation in 87% of the activities in which he participated.) On 6/22/25 at 09:55 AM, a Nursing Note is written that states: Per DON and other staff - resident finally fell asleep at 0130 AM this morning after being awake for 46 hours. Resident only took an hour and 40-minute nap in that 46-hour period.On 6/22/25 at 10:40 AM, a Nursing Note is written that states, in part: Narrative: Resident started on Risperidone is sound asleep currently lying in bed, vitals are stable, resident did have cares performed and has been repositioned. No adverse effects noted. Resident able to answer yes/no questions.On 6/22/25 at 17:10 (5:10 PM), a Summary Note is written that states, in part: Resident summary. Resident started risperidone on 6/21 due to behaviors and aggression. Resident got one time dose, plus prn dose and scheduled dose today. Resident is requesting to stay in bed, is arousable and able to conversate with staff. No aggression noted.On 6/23/25 at 12:36 PM, a Behavior Note is written that states, in part: Resident started on Risperidone is sound asleep currently lying in bed, vitals are stable, resident did have cares performed and has been repositioned. Resident has become physically aggressive with staff every time attempted to get out of bed. Meals offered in bed; Resident has taken 2 containers of Boost (Nutrition Supplement) from writer with Meds. Has had a very poor appetite but has been drinking with straw w/o (without) problems.R8's Minimum Data Set with Assessment Reference Date 6/23/25, indicates R8 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognitive impairment. Section E indicates physical and verbal behaviors directed at others occurred 1-3 days in the past 7 days. Section GG indicates R8 was independent with eating and rolling left/right, required set up/clean-up assistance with oral hygiene, and required partial/moderate assistance with upper body dressing. Section GG also indicates R8 required substantial/maximal assistance with shower/bathe self, moving from sitting to lying, lying to sitting, sit to stand, chair/bed to chair transfer, toilet transfer, tub/shower transfer, and walking 10 feet. R8 was indicated to be dependent with toileting hygiene and lower body dressing.On 6/24/25 at 06:00 AM, a Behavior Note is written that states: New order for Risperidone on 6/22/25. No adverse effects from medication, no behaviors noted this shift.On 6/24/25 at 11:38 AM, an Orders - General Note from eRecord Note is written that states: Resident sleeping during AM med pass, when awoken, resident refused medications and went back to sleep.On 6/24/25 at 14:51 (2:51 PM), a Behavior Note is written that states: Resident refused meals on this shift as well as fluids and medications. Resident becomes [sic] combative and abusive with staff with cares and interactions. Reapproach, distraction, 1:1 ineffective.On 6/24/25 at 14:53 (2:43 PM), a COMMUNICATION - with Physician Note is written that states, in part: Situation: Resident refusing cares, medications, fluids and meals and becomes combative with staff during care. Spouse/POA wanted resident evaluated in ER due to decreased oral intake.On 6/24/25 at 17:57 (5:57 PM), an eINTERACT SBAR Summary for Providers Note is written that states, in part: . Functional Status Evaluation: Needs more assistance with ADLs (Activities of Daily Living) Behavioral Status Evaluation: Physical aggression Verbal aggression Personality change Other behavioral symptoms. Abdominal/GI Status Evaluation: Decreased appetite/fluid intake. Nursing observations, evaluation, and recommendations are: resident came back from ER with hospice order wife requesting [Hospice Provider Name] hospice. Primary Care Provider responded with the following feedback: A. Recommendations: monitor per policy.(Of note: This is the last documentation of staff reporting decreased appetite and fluid intake and needing more assistance with ADLs until 8/7/25).On 6/24/25 at 19:12 (7:12 PM), a Health Status Note is written that states, in part: Resident is currently resting in bed with eyes closed. Work of breathing is regular with equal chest rise and fall. Resident continues to have brief moments of agitation with cares but returns to sleeping soon after. Resident continues to refuse drink or beverage.On 6/25/25 at 04:54 AM, a Clinical Follow Up Note is written that states, in part: Resident is on follow up for: Overall decline in condition; resident has decreased food and fluid intake; increased assist with ADLs; increased behaviors. The current status is resting in bed. No display of pain noted.On 6/25/25 at 09:28 AM, a Behavior Note is written that states: New order for Risperidone on 6/22/25. No adverse effects from medication, no behaviors noted this shift. Resident pleasant and cooperative with cares, up in w/c for breakfast and ate 100%.R8's Weight Documentation indicates R8 weighed 177.5 lbs. on 7/1/25.(Of note: This documentation indicates a 6.82% weight loss over 2 weeks between 6/16/25 and 7/1/25, and the risperidone was started on 6/22/25).On 7/3/25 at 11:20 AM, a Psychosocial Assessment is completed that indicates R8 has psychosocial symptoms related to his cognitive status, stating [Resident Name] is confused and sometimes has thoughts and his relationship with his wife and also with staff members . The assessment also states, . 1. Mood or Behavior concerns since last assessment: yelling, hitting, spitting, verbal threats, swearing. 2. Is resident on any psychotropic medications? 1. Yes. 2b. If Yes to Psychotropic medications, list psychotropic medications and target behaviors: Risperdal (Risperidone) TARGET BEHAVIOR 1: Physically aggressive behavior (pinching, kicking, biting or hitting) TARGET BEHAVIOR 2: Verbally aggressive or sexually inappropriate language. 3. Mental Health Services. 1. No Need.On 7/9/25, a Physician Order was placed to admit R8 to hospice with the diagnosis of coronary artery disease.R8's Significant Change Minimum Data Set with Assessment Reference Date, 7/10/25, indicates R8 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15, indicating severe cognitive impairment. Section GG indicates R8 requires supervision or touching assistance with eating and partial/moderate assistance with oral hygiene. Section GG also indicates R8 is dependent with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, personal hygiene, and roll left/right, chair/bed to chair transfer, and tub/shower transfer. R8 could not attempt moving from sit to lying, lying to sitting, sit to stand, toilet transfer, and walking 10 feet.(Of note: This MDS indicates a decrease in R8's functional abilities with e