Middletown Nursing And Rehabilitation Center

Based on interview and record review, the facility failed to ensure a resident's rights were honored related to being spoken to in a rude manner and being called a derogatory term in the presence of other staff members in a manner that was loud enough to be heard by others for 1 of 3 residents reviewed for Resident Rights. (Resident C) Findings include:In a interview with Certified Nurse Assistant (CNA) 4 on 2-2-26 at 3:25 p.m., she recalled a conversation with Licensed Practical Nurse (LPN) 3 on an unspecified date around supper time. LPN 3 had told her that Resident C had requested LPN 3 to pour her a cup of water from the pitcher in the resident's room. CNA 4 indicated LPN 3 told her she responded to Resident C that she had two hands and she could do it herself. She added Resident C was no longer as strong as she used to be. It struck me at the time that what she said was really rude; not sure I would call it abuse, but definitely rude. CNA 4 indicated on/around the same date as this verbal interaction, she witnessed LPN 3 refer to Resident C as fat. This occurred during the shift change report, at approximately 5:00 a.m. There was not really anybody but staff around, but she said it in a voice that was more of a regular tone, maybe even louder than usual, but if anybody else was around, they definitely would have heard her. I did tell [names of Executive Director and Director of Nursing] the next morning because all the higher ups [management staff] were gone. I felt it was more rude, not necessarily abusive. In an interview with the Executive Director (ED) on 2-2-26 at 11:45 a.m., he indicated on the morning of 1-6-26, a CNA reported to him a possible abuse situation with another resident. During the investigation of the allegation and interviews with other residents, family and staff, the ED was informed by a staff member she had overheard LPN 3 call Resident C, a fat a-s. He indicated the facility was unsure of the exact dates of the occurrence, but guessed it had occurred during the previous weekend, sometime between the evening of 1-2-26 and the morning of 1-6-26, as these were the dates in which LPN 3 had most recently worked on the night shift. In a telephone interview with LPN 3 on 2-2-26 at 1:46 p.m., she indicated Resident C, does not like me, for whatever reason. Supposedly, she said I called her a fat a-s. Now, she has called me a fat a-s on more than one occasion. Once, I was in her room with [name of CNA 5 and [name of Resident C] started in calling me a fat ass .Later, as we were walking down the hall, we were talking about it quietly, about her calling me that . The clinical record of Resident C was reviewed on 2-2-26 at 4:00 p.m. The resident's diagnoses included, but were not limited to paranoid personality disorder (a mental health condition), depression, and anxiety. Her most recent Minimum Data Set assessment, dated 10-25-25, indicated the resident's cognition was intact. A review of Resident C's care plans indicated she has a behavioral concern related to paranoid personality disorder, as demonstrated by .make false accusations against staff AEB [as evidenced by] believing staff is turning others against her, feels staff purposely ignores her, and believes staff is trying to hurt rather than help her. Interventions include, but are not limited to, .Explain all procedures to the resident before starting and allow the resident 2-3 minutes to adjust to changes .Resident will be attended to and have needs met with two staff in the room at all times. On 2-3-26 at 12:36 p.m., the Executive Director provided a copy of a policy with a review date of 12-31-25, and entitled, Resident Rights. This policy indicated, Employees shall treat all residents with kindness, respect, and dignity .Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity .Orientation (annually) and in-service (annually) training programs are conducted to assist our empl in understanding residents' rights. This citation relates to Intake 2709181. 3.1-3(a)(1)3.1-3(a)(2)(A)3.1-3(a)(2)(B)3.1-3(a)(2)(C)3.1-3(a)(2)(D)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that residents prescribed antipsychotic medications received appropriate gradual dose reduction (GDR) attempts and failed to provide documented clinical justification for the continued use of the antipsychotic medications for 2 of 5 residents reviewed for unnecessary medications. (Resident 3 and Resident 9) Findings include: 1. During an observation, on 11/19/25 at 3:32 p.m., Resident 3 quietly lay in bed with her eyes closed. During an observation, on 11/20/25 at 8:33 a.m., Resident 3 sat quietly in a Broda (high-backed wheeled reclining) chair in the dining room as she was assisted with eating. During an observation, on 11/20/25 at 12:02 p.m., Resident 3 sat quietly in a Broda chair in the dining room at a table with other residents. During an observation, on 11/21/25 at 11:59 a.m., Resident 3 sat quietly in her Broda chair as CNA 10 propelled her to the dining room. During an observation, on 11/24/25 at 10:20 p.m., Resident 3 quietly lay in bed with her eyes closed. Resident 3's clinical record was reviewed on 11/20/25 at 1:33 p.m. Diagnoses included Alzheimer's disease, neurocognitive disorder with Lewy Bodies, anxiety disorder, major depressive disorder, recurrent, severe with psychotic symptoms, nontraumatic intracerebral hemorrhage in cerebellum, and dementia, unspecified severity, with mood disturbances. Current orders included Abilify (antipsychotic) 2 mg every evening (11/15/24), vilazodone (antidepressant) 40 mg daily (6/21/22), and risperidone (antipsychotic) 1 mg twice a day (11/15/24). A significant change Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident was rarely or never understood. She had short- and long-term memory problems. She had severely impaired cognitive skills for daily decision making. She did not exhibit hallucinations or delusions during the assessment period. She did not exhibit physical symptoms directed towards others, verbal symptoms directed toward others, nor behavioral symptoms not directed towards others during the assessment period. She was not resistive to care during the assessment period. She was dependent on staff assistance for her activities of daily living. She received antipsychotic and antidepressant classes of medication. A GDR was clinically contraindicated on 9/5/25. A care plan, initiated and revised on 5/9/23, indicated the resident had the potential to be physically aggressive related to Alzheimer's dementia and neurocognitive disorder with Lewy Bodies as exhibited by hitting, kicking, pushing, and fighting during care. Interventions included the following: Administer medications as ordered. Monitor/document for side effects and effectiveness (5/29/23); Assess and anticipate resident's needs; food, thirst, toileting needs, comfort level, body positioning, pain, etc. (5/9/23); and Communication: provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of the source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of a staff member when agitated (5/9/23). A care plan, initiated and revised on 5/10/23, indicated the resident had a history of behavior problems related to the neurocognitive disorder with Lewy Bodies as exhibited by physical aggression, visual hallucinations, and bizarre behavior, specifically playing in and eating feces. Interventions included the following: Administer psychotropic medications as ordered. Monitor/document for side effects and effectiveness (5/10/23); Anticipate and meet resident's needs (5/10/23); and Explain all procedures to the resident before starting and allow the resident three to five minutes or more if needed to adjust to changes (5/10/23). A care plan, initiated and revised 5/5/23, indicated the resident used psychotropic medications (risperidone and Abilify) related to behavior management with diagnoses of major depressive disorder, recurrent, severe with psychotic symptoms as exhibited by visual hallucinations, physical aggression, and bizarre behaviors such as playing in and eating stool. Interventions included the following: Administer psychotropic medication as ordered by physician. Monitor for side effects and effectiveness every shift (5/5/23); Consult with the pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly (5/5/23); and Monitor/record occurrence of target behavior symptoms (wandering, disrobing, playing in and eating stool, violence/aggression towards staff/others, visual hallucinations) and document per facility protocol (5/5/23). A care plan, initiated 5/5/23 and revised 5/8/23, indicated the resident used an antidepressant medication. Interventions included administer antidepressant medications as ordered by the physician and monitor/document side effects and effectiveness every shift (5/5/23). A psychosocial note, dated 7/16/25 at 3:15 p.m., indicated the resident's mood appeared stable with no obvious depressive feelings. She had no behaviors which included no hallucinations, no delusional thinking, no obvious signs of anxiety episodes or other mood issues. The resident received Abilify, risperidone, and vilazodone for symptoms related to major depressive disorder, recurrent, severe with psychotic symptoms. The resident's representative refused the facility's efforts to attempt GDR's of any of the resident's psychoactive medication and do not allow the in-house physician to treat the resident. The resident's family physician treats the resident and declines all recommendations to GDR the resident's psychoactive medications. A plan of care note, dated 8/22/25 at 12:46 p.m., indicated the resident had no reported behaviors. The SSD notified the resident representative of the black box warning for the psychoactive medications. The resident representative indicated the family physician wanted the resident to take these medications. The resident's representative was advised to request a GDR from the physician for the psychoactive medication. The resident no longer experienced symptoms, and the resident's disease process prevented her from performing previously demonstrated behavioral symptoms. An appointment with the family physician was scheduled for 9/5/25. A pharmacy consultation report, dated 8/28/25, provided by the DON on 11/24/25 at 10:45 a.m., indicated the pharmacist commented that the resident received two antipsychotics for major depressive disorder with psychotic symptoms, Abilify 2 mg every evening since 6/27/23 and risperidone 1 mg twice a day since 4/28/23. The pharmacist recommended the resident's Abilify and risperidone be reviewed for a GDR and questioned if the resident was a candidate for a trial dose reduction of either agent, with perhaps a trial off Ability, and if the resident was receiving the lowest effective dose. The physician response, in which he checked a box, indicated he declined the recommendations above because GDR was clinically contraindicated for the resident because continued use was in accordance with the current standard of practice and a GDR attempt at this time was likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. The form had blank lines below the checked statement and did not provide a rationale for the declination of a GDR of the Abilify and risperidone. The physician signed the form on 9/5/25. A physician progress note, dated 9/5/25, indicated the resident was seen for dementia, hypothyroidism, and hypercholesterolemia. The resident's medications were listed with no changes marked. The physician examined the resident. The assessment indicated that the resident's medication list was reconciled and updated, and they will continue to take the medications as listed other than as excepted. The progress note for the resident's physician visit lacked a rationale for declining the GDR for the Abilify and risperidone. A pharmacy consultation report, dated 10/29/25, provided by the DON on 11/25/25 at 10:45 a.m., indicated the pharmacist commented that the resident had received vilazodone 40 mg every day for the management of major depressive disorder since 4/28/23. The pharmacist recommended a GDR of the vilazodone to 20 mg every day. The physician response, in which he checked a box, indicated he declined the recommendations above because GDR was clinically contraindicated for the resident because continued use was in accordance with the current standard of practice and a GDR attempt at this time was likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. The form had blank lines below the checked statement and did not provide a rationale for the declination of a GDR of the vilazodone. The physician signed the form on 11/3/25. During an interview, on 11/21/25 at 11:54 a.m., the SSD indicated behaviors were documented on a behavior sheet. She did not have any behaviors documented for the resident. The resident had been mostly calm since she had admitted to the facility. She had spoken to the resident's representative multiple times about the need to GDR the resident's antipsychotic medications. The resident's representative took the resident out of the facility to the family doctor. Even though the resident had no behaviors, the resident's representative did not want the resident's psychoactive medications reduced or discontinued. During an interview, on 11/21/25 at 11:59 a.m., RN 5 indicated she had spoken to the resident's representative in the past, and she had declined to allow a GDR of the resident's psychoactive medications. The resident was calm all the time. When the resident first arrived at the facility some time ago, she was occasionally tearful. But she had not been tearful for a while. During an interview, on 11/21/25 at 3:03, RN 8 indicated the resident was consistently calm. During an interview, on 11/24/25 at 2:12 p.m., CNA 7 indicated she had no problems at all with the resident having any behaviors. During an interview, on 11/24/25 at 2:35 p.m., the DON indicated she was aware the resident had no behavioral symptoms, but the resident representative and the physician declined to reduce and/or discontinue any of the resident's psychoactive medications. 2. During an observation, on 11/19/25 at 1:00 p.m., Resident 9 sat quietly in his wheelchair in the dining room and fed himself lunch. During an observation, on 11/19/25 at 3:51 p.m., Resident 9 lay quietly in his bed with the head of the bed elevated. His eyes were closed. During an observation, on 11/20/25 at 8:15 a.m., Resident 9 sat quietly in his wheelchair in the dining room and fed himself lunch. During an observation, on 11/20/25 at 10:24 a.m., Resident 9 sat in his room in his wheelchair and repeatedly stated, I need help. LPN 8 talked with resident, and he calmed. During an observation, on 11/20/25 at 12:02 p.m., Resident 9 sat in his wheelchair in the dining room and conversed with a visitor sitting at his table. During an observation, on 11/21/25 at 9:36 a.m., the SSD propelled Resident 9 in his wheelchair down the hall as he sat quietly and looked around. During an observation, on 11/24/25 at 9:57 a.m., Resident 9 sat quietly in his wheelchair at a table in the front lounge area with other residents. Resident 9's clinical record was reviewed on 11/21/25 at 9:16 a.m. Diagnoses included other specified depressive episodes and dementia, moderate, with agitation. Current orders included donepezil (for dementia) 10 mg daily at bedtime (8/4/25), escitalopram (antidepressant) 20 mg daily at bedtime (10/17/25), risperidone (antipsychotic) 1 mg daily at bedtime (10/23/25), quetiapine (antipsychotic) 25 mg twice a day (10/23/25), and tramadol-acetaminophen (for pain) 37.5/325 mg twice a day (8/16/25). A quarterly Minimum Data Set (MDS) assessment, dated 8/4/25, indicated the resident was moderately cognitively impaired. He did not exhibit hallucinations or delusions during the assessment period. He did not exhibit physical symptoms directed towards others, verbal symptoms directed toward others, nor behavioral symptoms not directed towards others during the assessment period. He was not resistive to care during the assessment period. He required supervision/touching assistance of staff with eating. With oral hygiene and rolling in bed, he required substantial/maximal staff assistance. He was dependent on staff assistance for toileting hygiene, showering/bathing, upper/lower body dressing, donning/doffing footwear, personal hygiene, and transfers. He required partial/moderate staff assistance with propelling his manual wheelchair for 50 to 150 feet. He received antipsychotic, antidepressant, and opioid classes of medication. The physician documented a GDR was clinically contraindicated on 11/6/25. A care plan, initiated and revised on 10/20/25, indicated the resident had a behavior problem related to dementia as exhibited by sexually inappropriate remarks, grasping, and agitation with verbal aggression. The interventions included the following: Administer medication as ordered. Monitor/document for side effects and effectiveness (10/20/25); Explain all procedures to the resident before starting and allow the resident time to adjust to changes (10/20/25); and 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 (10/20/25).A care plan, initiated and revised on 11/19/25, indicated the resident was physically aggressive on occasion including hitting, kicking staff related to dementia, moderate with agitation. The interventions included the following: The resident's triggers for physical aggression are during care specifically during nighttime hours. The resident's behaviors is de-escalated by waking resident gently, explaining procedure before attempting care (11/19/25); Assess and anticipate resident's needs - food, thirst, toileting needs, comfort level, body positioning, pain, etc. (11/19/25); Monitor/document/report as needed any signs or symptoms of resident posing a danger to himself and others (11/19/25); and When the resident becomes agitated: Intervene before agitation escalates. Guide resident away from source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later (11/19/25). A care plan, initiated 8/7/25 and revised 11/19/25, indicated the resident used psychotropic medications (quetiapine and risperidone) related to behavior management. The diagnosis was dementia, moderate with agitation, and included sexually inappropriate behaviors and combativeness during care. The interventions included the following: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift (8/7/25); Consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly (8/7/25); and Monitor/record occurrence of target behavior symptoms (inappropriate sexual behavior and language, aggression towards staff/others, etc.) and document per facility protocol (8/7/25). A care plan, initiated and revised 8/7/25, indicated the resident used an antidepressant medication related to depressive disorder. The interventions included: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift (8/7/25). A psychosocial progress note, dated 8/11/25 at 2:48 p.m., indicated the resident received quetiapine for signs and symptoms related to his dementia with behaviors including sexually inappropriate behaviors. He had a history of inappropriate behaviors prior to his stay in the facility. He had no behaviors, no hallucinations, no delusions, no anxiety and no other mood issues since admission to the facility. A psychosocial progress note, dated 9/2/25 at 10:45 a.m., indicated the SSD met with the resident's representative to discuss the resident's psychotropic medications and the black box warning for quetiapine. The resident's representative indicated the resident was prescribed the medication for inappropriate sexual behaviors at the previous facility. The resident representative declined to have a GDR of the quetiapine attempted because the resident was planned to return to the prior facility to live with his wife. A health status note, dated 9/3/25 at 11:32 a.m., indicated the resident was alert with periods of confusion. He had periods of combativeness which made care difficult at times. A health status note, dated 9/14/25 at 5:31 a.m., indicated the staff attempted to get the resident dressed and up for breakfast. He attempted to grab the CNA's bottom and made several inappropriate remarks. The CNA told the resident the remarks were inappropriate, and the resident said they were not. Then, the resident said he was going to break the CNA's hand. He tried to squeeze and twist the CNA's hand. The CNA removed her hand from the resident's hands and left the room to allow the resident to calm down. A health status note, dated 9/19/25 at 6:25 a.m., indicated the staff performed morning care when the resident threatened to knock out the staff's teeth. He drew his fist back and yelled for the staff to put some clothes on him. The staff were attempting to put clothing on him. A psychosocial note, dated 9/29/25 at 3:27 p.m., indicated a care plan meeting was held with the resident's representatives. The resident was no longer progressing in therapy and continued to require a mechanical lift for transfers. The consensus of the resident's representatives, therapy, and nursing was that resident would be unable to return to an assisted living facility. A health status note, dated 10/12/25 at 6:03 p.m., indicated the resident was agitated throughout much of the day, which was out of character for him. He was confused and yelled out throughout the day. A health status note, dated 10/14/25 at 6:03 a.m., indicated the resident became combative with staff during morning care. He attempted to hit and kick staff. A psychosocial note, dated 10/15/25 at 4:07 p.m., indicated the resident was to remain in the facility with no discharge plans. A health status note, dated 10/16/25 at 11:59 p.m., indicated the physician increased the resident's escitalopram medication from 10 mg to 20 mg daily. A behavior note, dated 10/17/25 at 6:32 a.m., indicated the resident was on his roommate's side of the room. The resident threatened to knock the roommate's head off. He had his fist drawn back and refused to leave. The staff assisted the resident from the room. A psychosocial note, dated 10/17/25 at 11:02 a.m., indicated the resident did not recall threatening or yelling at his roommate. The resident was moved to another room. The resident representative indicated the resident's behavior was out of character for him. A Behavior Referral form, dated 10/23/25 at 5: 15 a.m., provided by the SSD on 11/21/25 at 12:15 p.m., indicated the resident's behaviors observed were verbal abuse, physical abuse, and resistance to care. The resident needed incontinence care. The behavior was semi existing as he went from verbal to physical behaviors. The staff provided incontinence care. When the resident was rolled, he yelled, cursed, and threatened staff. The staff explained to the resident he needed changed and to get ready for the day. Staff waited, went back, and pulled up the resident's brief. The resident punched the staff in the arm several times. The staff moved away from resident. The resident grabbed the staff and attempted to pull the staff into bed. The staff covered the resident with a sheet and left the room. A health status note, dated 10/23/25 at 5:19 a.m., indicated when a male staff member began to dress and turn the resident in bed, the resident hit the staff member in the arm and tried to drag the staff member closer to the resident. The staff member walked away from the resident. The Director of Nursing (DON) was notified. A health status note, dated 10/23/25 at 1:33 p.m., indicated the physician came to the facility and ordered risperidone 1mg at bedtime and increased the resident's quetiapine from 25 mg daily to 25 mg twice a day. Labs were ordered. A physician's progress note, dated 10/23/25, indicated the physician saw the resident for an acute visit regarding behaviors. He performed a review of systems and a physical assessment. He indicated the resident was positive for agitation and behavioral symptoms. His assessment and plan was to increase the quetiapine and add risperidone to the resident medication regimen. The notes lacked additional rationale for the changes in the resident's psychotropic medications. A health status note, dated 10/25/25 at 6:11 a.m., indicated the resident became combative with morning care. He cussed and told the staff he was going to knock their heads off. He swung his fist back and attempted to hit the staff. A health status note, dated 10/27/25 at 4:34 p.m., indicated no new orders were received related to the resident's recent lab results. The resident appeared to be agitated. A pharmacy consultation report, dated 10/29/25, provided by the DON on 11/24/25 at 10:45 a.m., indicated the pharmacist commented the resident received two or more antipsychotics which included risperidone 1 mg every bedtime and quetiapine 25 mg twice a day. Evidence for the use of multiple antipsychotics was limited and increased the risk for drug interactions, medication errors, and cumulative side effects. His recommendation was to consider discontinuing quetiapine and consider adding a morning dose of risperidone if the resident's behaviors increased after the quetiapine was discontinued. On 11/6/25, the physician indicated he had re-evaluated the therapy and did not wish to implement any changes due to the resident was stable on his current medications. A change would be disruptive to the resident care and potentially harmful. A Behavior Referral form, dated 11/10/25 at 7:30 a.m., provided by the SSD on 11/21/25 at 12:15 p.m., indicated the resident's behaviors observed were verbal abuse, physical abuse, and resistance to care. The resident was asked to do a task and needed incontinence care. A female staff member provided incontinence care. A male staff member heard the resident yelling and cursing. The male staff member attempted to explain to the resident they were helping him, and he was dirty. During incontinence care, the resident yelled, kicked, and swung his arms. The staff quickly put resident's brief on him, covered him, and left the room. A Behavior Referral form, dated 11/14/25 at 3:30 a.m., provided by the SSD on 11/21/25 at 12:15 p.m., indicated the resident's behaviors observed were verbal abuse and physical abuse. The resident needed incontinence care. The staff attempted to provide incontinence care, and the resident stated What the he** are you doing? Staff told the resident they needed to change him because his brief was wet. The resident hit, pulled at the staff's hands, and kicked at staff. The staff left the room for a moment then returned. The resident continued to hit staff during the incontinence care. A psychosocial note, dated 11/14/25 at 9:07 a.m., indicated the resident became combative during incontinence care. The staff left the room and returned, but the resident remained resistant and combative, such as hitting and kicking at staff. During an interview, on 11/20/25 at 3:23 p.m., CNA 6 indicated she had never had any problems providing care for the resident. He was very sweet. During an interview, on 11/21/25 at 2:59 p.m., RN 8 indicated the resident got mad and yelled if incontinence care was not done fast enough. The resident gradually started swinging at the staff, and it was not consistent behavior. The yelling though was common. He had improved since his family member had recently moved to the facility. During an interview, on 11/24/25 at 2:12 p.m., CNA 7 indicated she had no difficulties providing the resident's care. She just had to give him a few minutes to wake up and tell him what she was going to do then he was fine. During an interview, on 11/24/25 at 2:26 p.m., the DON indicated she had not seen the resident's behaviors but heard he grabbed and pushed at the staff. She was uncertain if the behaviors were psychotic behaviors or dementia behaviors, but his behaviors had improved since the medications had been changed. During an interview on 11/24/25 at 3:27 p.m., the SSD indicated she had received no additional behavioral referrals for Resident 9 other than the three she had provided. The black box warning for risperidone was retrieved on 11/24/25 from the FDA website at www.accessdata.fda.gov/drugsatfda_docs/label/2009/020272s056,020588s044,021346s033,021444s03lbl.pdf. The guidance indicated .WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS .Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. The indications for use for risperidone include the following: schizophrenia, bipolar mania, and irritability associated with autistic disorder in children and adolescents aged 5 to [AGE] years old. The black box warning for quetiapine was retrieved on 11/24/25 from the FDA website at www.accessdata.fda.gov/drugsatfda_docs/label/2020/020639s069lbl.pdf. The guidance indicated .WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS .Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. The indications for use for quetiapine included schizophrenia, bipolar I disorder manic episodes, and bipolar disorder, depressive episodes. A current facility policy, dated 12/31/24, titled Tapering Medications and Gradual Drug Dose Reduction, provided by the DON on 11/24/25 at 3:00 p.m., indicated the following: .Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.For any individual who is receiving an antipsychotic medication to treat behavioral symptoms related to dementia, the GDR may be considered clinically contraindicated if: a. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and b. The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. A current facility policy, dated 12/31/24, titled Antipsychotic Medication Use, provided by the DON on 11/24/25 at 3:00 p.m., indicated the following: .Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.Antipsychotic medication shall generally be used only for the following conditions/diagnoses as documented in the record consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence or presence of dementia: g. Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high-dose steroids); h. Tourette's Disorder; i. Huntington Disease; j. Hiccups (not induced by other medications); or k. Nausea and vomiting associated with cancer or chemotherapy.Diagnoses alone do not warrant the use of antipsychotic medications. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident and others; AND; (1) The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) Behavioral interventions have been attempted and included in the plan of care, except in an emergency.The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. 3.1-48(a)(4)3.1-48(b)(2)

Based on observation and interview, the facility failed to provide residents with dignified dining for 3 of 8 people reviewed for dining. (Residents 3, 4, and 11).Findings include:During a breakfast observation, on 11/20/25 at 8:25 a.m., the following was observed:CNA 7 was standing to the right side of Resident 3 while assisting her with eating. After offering Resident 3 a bite of food, CNA 7 walked over to Resident 4 and offered him a bite of food while standing on Resident 4's left side. CNA 7 walked back and forth between Resident 3 and 4 while offering the residents bites of food. CNA 7 did not sit down any time during the continuous meal service observation.CNA 6 walked over and stood to the right side of Resident 11 who was sitting at the table. CNA 6 offered Resident 11 a bite of oatmeal while she continued to stand next to Resident 11. After Resident 11 took a bite of oatmeal, CNA 6 then proceeded to walk around the dining room cueing semi-dependent residents to eat their meal.Resident 3's clinical record was reviewed on 11/20/25 at 1:33 p.m. Diagnoses included Alzheimer's disease, neurocognitive disorder, dementia and mood disturbance.A 10/1/25, significant change, Minimum Data Set (MDS) assessment indicated Resident 3 was dependent on staff with meals.Resident 11's clinical record was reviewed on 11/20/25 at 2:11 p.m. Diagnoses included history of a stroke, age related physical disability, and cognitive decline.An 11/12/25, quarterly, Minimum Data Set (MDS) assessment indicated Resident 11 needed touching assistance with meals.Resident 4's clinical record was reviewed on 11/21/25 at 10:05 a.m. Diagnosis included weakness, lack of coordination, and contracture of left hand.A 10/29/25, quarterly, MDS assessment indicated Resident 4 was a partial staff assist with meals.During an interview, on 11/20/25 at 2:42 p.m., CNA 7 indicated she was standing while assisting residents with their meals. There wasn't enough room to feed all the dependent residents at the same table. They would still need to walk between the residents so everyone could be fed without their food getting cold.During an interview, on 11/20/25 at 3:10 p.m., CNA 6 indicated she sometimes stood during breakfast meal service. They didn't have enough help assisting the residents with meals, so they stood to go back and forth between the residents.During an interview, on 11/21/25 at 3:35 p.m., the DON indicated, when assisting residents with meals, staff members should be sitting down, eye level with the residents. Usually, the staff members sat between two residents to assist them with meal service.A current facility policy, titled Assistance with Meals, provided by the Activity Director on 12/1/22 at 11:44 a.m., indicated the following: .3. Residents Requiring Full Assistance: B. Residents who cannot fed themselves will be fed by the nursing staff with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals.3.1-3(t)

Based on observation and interviews, the facility failed to store, prepare, and distribute foods under safe sanitary conditions regarding the removal of dented cans of food and the cleaning of the stove hood. This deficiency had the potential to impact 14 of 14 residents residing in the facility.Findings include:During a kitchen observation, on 11/19/25 at 9:42 a.m., accompanied by the Dietary Manager, the following was observed:In the facility's dry storage area, each of five cans of Mandarin oranges were severely dented on the top seal of the cans. The cans had an intake date of 11/4/25. A can of butterscotch pudding was dented on the top seal with an intake date of 10/7/25. A can of sliced apples was dented on the top seal with an intake date of 3/25/25. A can of cream of mushroom soup had a dented top seal.The stove hood had a dish rag placed between the stove hood and the fire sprinkler pipe. The rag was covered in dark brown and black colored grease. The stove hood was marked as last serviced May 2025.The Dietary Manager indicated, at the time of observation, that staff members avoid the dented area when opening the cans. The food in the dented cans were still used. Staff members would open the cans halfway to avoid the dented area before serving the cans contents. She had been the Dietary Manager for a year. The stove hood should have been free of any debris.A current facility policy titled, Food Receiving and Storage, provided by the Administrator, on 11/24/25 at 10:17 a.m., indicated the following: .When food is delivered to the facility it will be inspected for safe transport and quality before being accepted 3.1-21(i)(1)(3)

Based on record review and interview, the facility failed to ensure residents were offered up to date information on current vaccinations available for 2 of 5 residents reviewed for immunizations. (Resident 4 and Resident 6) Findings include:1. Resident 4's clinical record was reviewed on 11/21/25 at 10:05 a.m. Diagnoses included type 2 diabetes mellitus with hyperglycemia, dyspnea, unspecified, presence of coronary angioplasty implant and graft, and chronic kidney disease, stage 4. Resident 4 received the pneumococcal polysaccharide vaccine (PPSV) 23 on 11/30/2007 and the pneumococcal conjugate vaccine (PCV) 13 on 9/14/15. The clinical record lacked offering for consent or declination for the PCV 20 or the PCV 21. 2. Resident 6's clinical record was reviewed on 11/21/25 at 10:31 a.m. Diagnoses included chronic diastolic (congestive) heart failure, presence of coronary angioplasty implant and graft, and atherosclerotic heart disease of native coronary artery without angina pectoris. Resident 6 received the PCV 13 on 6/24/15 and the PPSV 23 on 11/27/19. The clinical record lacked offering for consent or declination for the PCV 20 or the PCV 21. During an interview, on 11/24/25 at 1:57 p.m., the DON indicated she was unable to locate documentation that the PCV 20 or 21 was offered to Resident 4 or Resident 6. During an interview, on 11/24/25 at 2:14 p.m., the DON indicated both residents should have been offered the PCV 20. According the CDC website, retrieved on 11/25/25 at www.cdc.gov/pneumococcal/vaccines/adults.html#cdc_vaccine_recommendations_section_3-older-adults-who-received-pcv13-and-ppsv23, adults 65 years or older who have received the PCV 13 and PPSV 23 (at or after the age of 65 years) have the option to get the PCV20 or the PCV 21, or to not get additional pneumococcal vaccines based on shared clinical decision making between the adult and the vaccine provider. A current facility policy, dated 12/31/24, titled Pneumococcal Vaccine, provided by the Administrator on 11/24/25 at 2:25 p.m., indicated the following: .Administration of the pneumococcal vaccine or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination. 3.1-13(a)

Based on observation, interview, and record review, the facility failed to maintain the stove hood in a cleanly manner. This had the potential to affect 12 of 12 residents in the facility.
Findings include:
A tour of the kitchen was conducted with the Dietary Manager (DM) on 11/22/24 at 12:00 p.m. During the tour, an observation of the stove hood was made. There were several intricate looking cobwebs strung between the gaps in the vent covers on the left side of the hood. The cobwebs were brown in color. There was fuzzy debris built up on the right side of the hood. These areas were directly above the stove.
An interview was conducted with Dietary Aide 5 during observation of the stove hood. She indicated a separate company was responsible for cleaning the stove hood, and it had been a couple of months since they came.
On 11/22/24 at 12:56 p.m., an interview was conducted with the DM, who provided the, 3/4/24, service report from the company who cleaned the facility's stove hood. The service report indicated the exhaust hood was cleaned on 3/4/24. The DM indicated the Maintenance Director provided her with the, 3/4/24, service report as verification of the last time the stove hood was cleaned. She was unsure how often it was supposed to be cleaned, but the stove hood was pretty bad during the tour.
On 11/22/24 at 12:45 p.m., the DM provided verification of a, 10/1/24, semi-annual kitchen hood suppression inspection and the, 10/23/24, wet and dry fire sprinkler system inspection reports. None of them referenced cleaning of the stove hood.
An interview was conducted with the DM on 11/22/24 at 1:17 p.m. She indicated there was no facility policy on cleaning the stove hood, but they were due for a cleaning this month.
3.1-21(i)(3)

3. During an observation on 11/22/24 at 11:56 a.m., Resident 11 was sitting in her recliner. The resident had a bottle of formula for a gastrostomy tube (feeding tube) hanging on a pole with a piston (syringe for administering formula, medication, and water into the gastrostomy tube and checking placement of the gastrostomy tube) hanging next to the formula bottle in a bag with no date. Observation of the resident's room and bathroom indicated there was no PPE visible.
During an interview on 11/22/24 at 12:55 p.m., the DON verified the piston syringe was not dated. The DON indicated the nurse was responsible to date the piston syringe when it was opened. The DON verified there was no PPE located in Resident 11's room.
The clinical record for Resident 11 was reviewed on 11/25/24 at 11:10 a.m. The diagnoses included, but were not limited to, dementia, gastrostomy status, congestive heart failure, hypertension, anxiety and diabetes.
The physician recapitulation for Resident 11, dated November 2024, indicated the resident was to have the peg-tube (artificial nutrition through a tube into the stomach) flushed with 60 milliliters (ml) of water, check tube placement and residual prior to administration of formula or flushing of the feeding tube.
During an interview on 11/25/24 at 11:40 a.m., Registered Nurse (RN) 1 indicated the facility does not have a policy for enhanced barrier precautions (EBP).
The enteral nutrition policy was provided by RN 1 on 11/25/24 at 1:30 p.m. The policy indicated the staff caring for residents with feeding tubes would be trained on potential adverse effects of tube feeding, such as feeding-tube complications.
3.1-18(b)(1)
3.1-18(b)(2)
Based on observation, interview, and record review, the facility failed to ensure the use of enhanced barrier precautions (EBP) for 3 of 3 residents reviewed for EBP (Resident 3, Resident 11, and Resident 2), and failed to ensure a feeding tube piston syringe was dated for 1 of 1 resident reviewed for enteral feeding management (Resident 11).
1. The clinical record for Resident 3 was reviewed on 11/25/2024 at 11:30 a.m. The medical diagnoses included chronic kidney disease.
A Quarterly Minimum Data Set Assessment, dated 11/13/2024, indicated Resident 3 had an indwelling urinary catheter.
A physician order, dated 5/16/2024, indicated Resident 3 utilized an indwelling urinary catheter.
A urinary care plan, last revised 11/15/2024, indicated Resident 3 utilized an indwelling urinary catheter. The care plan did not indicate the use of EBP.
During an interview on 11/22/2024 at 12:29 p.m., Certified Nursing Assistant (CNA) 2 indicated she did not know what EBP was. When she provided care to residents with indwelling medical devices, such as catheters and feeding tubes, she only utilized gloves, but not a gown or other personal protective equipment.
During an interview on 11/22/2024 at 12:45 p.m., the Director of Nursing (DON) indicated the facility did not have anyone on EBP and they did not utilize it currently.
2. The clinical record for Resident 2 was reviewed on 11/26/24 at 10:12 a.m. The diagnoses included, but were not limited to, congestive heart failure, pleural effusions, and acute and chronic respiratory failure with hypoxia.
A physician's order, dated 8/2/24, indicated Resident 2 received catheter care every shift and an order, dated 8/5/24, indicated Resident 2 was to have the hospice provider complete pleural drain care two times per week.
An observation conducted, on 11/22/24 at 11:10 a.m., indicated no enhanced barrier precaution signage was in Resident 2's room or any personal protective equipment (PPE) was located in or near the resident's room.

Based on interview and record review, the facility failed to report required nursing staffing data to the payroll based journal (PBJ) for April 1-June 30, 2023, for 1 of 1 Quarter reviewed on Certification and Survey Provider Enhanced Reporting (CASPER).
Findings include:
A PBJ Staffing Data Report, dated 9/12/2023, indicated it encapsulated data from April 1-June 30, 2023, and was triggered for failure to submit data for the quarter.
A Staff Activity Report, dated for 9/18/2023, indicated that no staffing hours were reported between April 1-June 30, 2023.
An interview with the Business Office Manager on 9/18/2023 at 1:30 p.m., indicated that she reported the PBJ information quarterly by manually entering the data into the system.
An interview with the Business Office Manager on 9/18/2023 at 2:30 p.m., indicated that did not have validation report and confirmed that no hours had been reported for April 1-June 2023 per the Staff Activity Report for that timeframe.
A policy entitled, Staffing, was provided by the Business Office Manager on 9/19/2023 at 2:22 p.m. The policy indicated, .Our facility furnished information from payroll records setting forth the hours worked by nursing personnel on each day for each quarter and reported to the appropriate state agency .

Based on interview, and record review, the facility failed to develop or update care plans for the use of Prolia, new skin impairments, a bolster mattress and antidepressant for Resident 9. This affected 3 of 11 residents reviewed for care plan development. (Residents 2, 4, and 9)
Findings include:
1. Resident 2's record was reviewed on 9/21/23 at 11:33 a.m. The record indicated Resident 2 had diagnoses that included, but were not limited to, osteoporosis (weakened bones).
Current physician's orders included, but were not limited to, Prolia, 60 milligrams, given under the skin one time a day, every 180 days for osteoporosis, with a start date of 6/23/2023.
No care plan could be found for the medication nor the diagnosis.
On 9/22/23 at 11:28 a.m., the Director of Nurses indicated they do not have a care plan for the use of Prolia to treat osteoporosis.
2. The clinical record for Resident 4 was reviewed on 9/19/2023 at 11:10 a.m. The medical diagnoses included diabetes and kidney disease.
A Quarterly Minimum Data Set Assessment, dated for 6/8/2023, indicated that Resident 4 was cognitively intact and at risk for developing pressure ulcers.
An observation on 9/19/2023 at 10:12 a.m. indicated that Resident 4 had on pressure relieving boots and had a foam dressing to his left gluteal. An interview with LPN 3 at this time indicated that Resident 4 had two open areas to his left gluteal that were in the stages of healing, and they were utilizing a foam dressing to treat.
A physician order, dated for 9/4/2023, indicated to change the foam dressing to Resident 4's dressing as a treatment for .open areas on left gluteal.
Review of the care plans indicated Resident 4 was at risk for developing skin impairments but did not encapsulate the open areas to his left gluteal.
An interview with the Director of Nursing on 9/21/2023 at 1:45 p.m. indicated the facility did not have a care plan to address the current open areas to Resident 4's left gluteal.
3. The clinical record for Resident 9 was reviewed on 9/20/2023 at 1:41 p.m. The medical diagnoses included diabetes and anxiety disorder.
A Quarterly Minimum Data Set Assessment, dated for 8/2/2023, indicated that Resident 9 was cognitively impaired, had one fall during the review period, and utilized antianxiety medications.
An observations on 9/19/2023 at 1:45 p.m. indicated Resident 9 was sleeping in her recliner and had bolsters to her mattress.
An observations on 9/20/2023 at 10:45 a.m. indicated Resident 9 was sitting in her recliner and had bolsters to her mattress.
A physician order, dated for 9/8/2023, indicated Resident 9 utilized Zoloft (an antidepressant) for anxiety.
Review of the care plans for Resident 9 did not indicate the use of a bolster mattress.
A care plan, dated for 6/29/2023, indicated that Resident 9 utilized antianxiety medications (Buspar) but did not encapsulate the use of Zoloft.
An interview with the Director of Nursing on 9/21/2023 at 1:50 p.m. indicated that the facility did not have a care plan to utilize a bolster mattress for Resident 9 nor have a care plan for her use of Zoloft.
A policy entitled, Care Planning-Interdisciplinary Team, was provided by the Director of Nursing on 9/22/2023 at 10:45 a.m. The policy indicated, .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of individualized comprehensive care plan for each resident .
3.1-35(a)
3.1-35(b)(1)