**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident #15 1. Resident Status Resident #15, age [AGE], was admitted on [DATE]. According to the April 2024 CPO, diagnoses included dementia with behavioral disturbances, bipolar disorder (mental illness causing shifts in mood, energy, activity levels, and concentration), personality disorder (thoughts, feelings, and behaviors different from an established societal norm), anxiety, arthritis, history of falls, contractures (permanent tightening of the muscles and tendons causing joints to shorten and stiffen) of right foot ankle and hand and chronic kidney disease. The 3/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance from one staff member for dressing, toileting, and setup with personal hygiene. Section E of the MDS indicated Resident #15 had not exhibited behavioral symptoms of hitting, kicking, pushing, grabbing, threatening others, screaming at others, or cursing at others. A review of the resident's care plan revealed the resident had a care plan for antipsychotic medication, initiated on 9/21/23 and revised on 10/13/23. It read Resident #15 was taking an antipsychotic medication for a diagnosis of bipolar disorder to assist with symptom management. Although a review of the psychotropic medication review on 12/19/24 revealed no documentation of behaviors for either of the resident's diagnoses to support and clarify the rationale for the use of the antipsychotic or the antidepressant, a review of January, February, March, and April 2024 MAR revealed orders with a start date of 9/21/23 for: -Risperdal (an antipsychotic) oral tablet 0.5 MG by mouth at bedtime for vascular dementia with behaviors. -Effexor (an antidepressant) oral capsule extended release (ER) 24 hour 150 mg (Venlafaxine HCl). Give 150 mg by mouth one time a day for MDD (major depressive disorder). 2. MRR review a. MRRs 11/10/23, 12/14/23, 1/15/24, 3/22/24, and 4/9/24 - with recommendations The 11/10/23 MRR identified Resident #15 was receiving multiple medications that had the potential of affecting electrolytes and renal clearance. Recommendations included obtaining the following labs: comprehensive metabolic panel (CMP) (The 14 tests included in a CMP are: alkaline phosphatase(ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, blood urea nitrogen (BUN), creatinine, sodium, potassium, carbon dioxide, chloride, albumin, total protein, glucose, and calcium) a complete blood count (CBC) (a CBC is used to identify conditions including anemia, infection and leukemia), an A1C (measures blood sugar), and a lipid panel. The 12/14/23, MRR inquired if a gradual dose reduction (GDR) for the medication Effexor had been attempted for Resident #15 or was a GDR likely to worsen or destabilize the resident's condition, had a GDR been tried in the past and failed and if so on what date, or was there another response the physician would like to provide. The 1/15/24 MRR inquired if a GDR for the Risperdal had been attempted for Resident #15 or was a GDR likely to worsen or destabilize the resident's condition, had a GDR been tried in the past and failed and if so on what date, or was there another response the physician would like to provide. The 3/22/24 MRR inquired if a GDR for venlafaxine (Effexor) 150 mg (started on 9/21/23; no GDR on file) and Risperdal 0.75 mg (started 10/5/23; no GDR on file) could be attempted or would a GDR likely to worsen or destabilize the residents condition, had a GDR been tried in the past and failed and if so on what date, or was there another response the physician would like to provide. The MRR also asked for a monthly fasting blood glucose check or quarterly HbA1C (blood test used to diagnose type 2 diabetes) related to the use of an antipsychotic medication. The 4/9/24 MRR indicated that combining methocarbamol (muscle relaxant) and oxycodone (narcotic pain medication), per the April medication administration record ordered on 4/5/24 for muscle spasm and severe pain, increased risks of central nervous system (CNS) depression, psychomotor impairment, and respiratory depression and recommended monitoring adverse effects and the following labs were needed: CMP, CBC, a1c and a lipid panel. b. Lack of documentation to show review and response to the MRR recommendation by the medical provider, the medical director, or the DON. A comprehensive review of Resident #15's electronic medical record (EMR) on 4/25/24 and MRRs above revealed no documentation that the above recommendations had been reviewed and acted upon by the medical provider, the medical director, and the DON prior to 4/25/24, during the survey.Based on interviews and record review, the facility failed to implement policies and procedures that ensured potential irregularities identified by the consulting pharmacist (CP) and documented in monthly drug regimen reviews (MRRs) as recommendations, would be timely reviewed and acted upon by the medical provider, medical director, and the director of nursing (DON). This failure affected four of four residents (#51, #60, #15, #64) whose records were reviewed. In an interview, the CP responsible for the facility's MRRs stated she emailed the residents' MRRs to the DON monthly. There had been no response to the MRR recommendations for four months, beginning in January 2024. She further stated she had repeatedly notified the medical director, the DON, and the nursing home administrator (NHA) that she was not receiving any response from the facility to her recommendations. A review on 4/25/24 of an executive summary report by the pharmaceutical company revealed multiple MRR recommendations in January 2024 (163), February 2024 (143), March 2024 (131), and April 2024 (138) that had not been returned to the CP to show they had been reviewed and responded to by the medical provider. Further, on 4/24/24 at 2:00 p.m., the DON provided MMRs for Residents #51, #15, #60, and #64 that were not reviewed and signed by the medical provider until 4/25/24, during the survey. These included: -MRRs for Resident #51, dated 3/20/24, 3/22/24, and 4/10/24, which included recommendations to address two medications with anticoagulation properties, an antipsychotic medication without a clinically appropriate indication for use, and an antidepressant. -MRRs for Resident #15, dated 11/10/23, 12/14/23, 1/15/24, 3/22/24, and 4/9/24 which included recommendations to address gradual dose reduction (GDR) of an antipsychotic and antidepressant, lab studies, and pain medication. -MRRs for Resident #60, dated 11/10/23, 12/14/23, 2/15/23, and 3/21/24, which included recommendations addressing GDRs of antidepressants and inquiries about two medications with anticoagulation properties. -MRR for Resident #64, dated 3/22/24, which identified the resident's anticoagulant lacked the diagnosis listed in the resident's diagnosis list. The facility's failure to implement policies and procedures that ensured timely review and response to MRR recommendations created a situation of immediate jeopardy for serious resident harm - potential adverse consequences due to the lack of timely oversight of the residents' medication therapies. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy The facility failed to implement policies and procedures that ensured potential irregularities identified by the consulting pharmacist (CP) and documented in monthly drug regimen reviews (MRRs) as recommendations would be timely reviewed and acted upon by the medical provider, medical director, and the director of nursing (DON). In an interview, the CP responsible for the facility's MRRs stated she emailed the residents' MRRs to the DON monthly. There had been no response to the MRR recommendations for four months, beginning in January 2024. She further stated she had repeatedly notified the medical director, the DON, and the NHA that she was not receiving any response from the facility to her recommendations. A review on 4/25/24 of an executive summary report prepared by the pharmaceutical company revealed multiple MRR recommendations in January 2024 (163), February 2024 (143), March 2024 (131), and April 2024 (138) that had not been returned to the CP to show they had been reviewed and responded to by the medical provider. Further, on 4/24/24 at 2:00 p.m., the DON provided MMRs for Residents #51, #15, #60, and #64 that were not reviewed and signed by the medical provider until 4/25/24, during the survey. These included: -MRRs for Resident #51, dated 3/20/24, 3/22/24, and 4/10/24, which included recommendations to address two medications with anticoagulation properties, an antipsychotic medication without a clinically appropriate indication for use, and an antidepressant. -MRRs for Resident #15, dated 11/10/23, 12/14/23, 1/15/24, 3/22/24, and 4/9/24 which included recommendations to address gradual dose reduction (GDR) of an antipsychotic and antidepressant, lab studies, and pain medication. -MRRs for Resident #60, dated 11/10/23, 12/14/23, 2/15/23, and 3/21/24, which included recommendations addressing GDRs of antidepressants and inquiries about two medications with anticoagulation properties. -MRR for Resident #64, dated 3/22/24, which identified the resident's anticoagulant lacked the diagnosis listed in the resident's diagnosis list. The facility's failure to implement policies and procedures that ensured timely review and response to MRR recommendations created a situation of immediate jeopardy for serious resident harm - potential adverse consequences due to the lack of timely oversight of the residents' medication therapies. B. Facility notice of immediate jeopardy On 4/25/24 at 3:15 p.m., the NHA was notified of the facility's failure to implement policies and procedures that ensured potential irregularities identified in monthly drug regimen reviews (MRRs) would be timely reviewed and acted upon by the medical provider, medical director, and the DON created a situation of immediate jeopardy for serious harm if immediate action was not taken. C. Plan to remove immediate jeopardy On 4/25/24 at 5:47 p.m., the NHA implemented an interim plan to ensure the safety of all residents until a formal final plan could be submitted on 4/26/24. It read, in part, that immediately following the discovery of missing follow-up of MRRs for residents, the MRRs for Residents # 51, #15, #60, and #64 were reviewed and given to residents' providers for review and follow-up on recommendations. Based on physician review, appropriate changes were made to residents' medication regimens as needed. Education was completed with DON and Assistant DON regarding follow-up with MRRs on 4/25/24. On 4/26/24 at 1:05 p.m. the facility submitted its final plan to remove immediate jeopardy. The plan read: Immediately following discovery of missing follow up of Medication Regimen Reviews for residents. 1. MRRs for Residents #51, #15, #60, and #64 were reviewed and given to residents' providers for review and follow up on recommendation. Based on physician review, appropriate changes were made to residents' medication regimen[s] as needed. 2. Family and physician notification for Resident #51, #15, #60 and #64 was completed on 4/25/24. 3. Education completed with DON and assistant director of nursing (ADON) regarding follow up with MRRs on 4/25/24. Identification of Others: Prior to the notification of Immediate Jeopardy on 4/25/24, DON/designee began reviewing January 2024 to present MRRs with resident's provider on 4/23/24 to assure recommendations were reviewed by the provider. This included all residents with recommendations. All recommendations will be reviewed and completed by residents' providers by 4/29/24. Systemic Measures: 1. Beginning 4/25/24 the DON/designee will begin reporting to the NHA and vice president (VP) of Clinical Services to ensure monthly MRR follow up has been completed. Review tool to be completed to document completing of review. 2. Beginning 4/25/24 the pharmacy consultant will email monthly reports to the attending physician, the Medical Director, DON, NHA, VP of Clinical Services, and Director of Operations for review and follow up. In addition, hard copies will be provided to providers during regular visits to the community. 3. Facility pharmacy consultant will complete an Interim Medication Regimen Review (IMRR) on all new residents admitted to the facility twice per week to ensure new admissions are reviewed that would discharge from the facility prior to when monthly MRRs are completed. Monitoring 1. MRRs will be reviewed monthly by DON/designee to ensure recommendations have been reviewed/completed by the provider. Findings will be reported to the QAPI (quality assurance performance improvement) meeting held monthly for further review and recommendation. D. Removal of immediate jeopardy On 4/26/24 at 1:05 p.m., the NHA was notified that the facility's plan to remove immediate jeopardy was accepted based on the facility's actions in implementing the measures above. However, the deficient practice remained at an F level, the potential for more than minimal harm that is widespread. II. Facility policy and procedures A. The NHA provided the facility's Drug Regimen Review Policy, dated 7/10/23, on 4/25/24 at 5:28 p.m. It read in pertinent part: -Drug regimen review (DRR) consists of reviewing and analyzing prescribed medication therapy and medication use, including nursing documentation of medication ordering and administration. -The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. -Findings and recommendations are reported to the Administrator, director of nursing (DON), the primary physician, and the medical director, where appropriate. -The consultant pharmacist documents the date each review is completed on the appropriate form and briefly notes the findings. -Facility responsibility: To establish policies and procedures that address response timeframes for monthly DRR. -The consultant pharmacist (CP) documents potential or actual mediation therapy problems and communicates them to the primary physician and the DON. A written report is provided to the physician within seven working days. The physician's response is documented in the consultant pharmacist review record or elsewhere in the resident's medical record. -The physician response is provided to the consultant pharmacist for review and then filed by the facility. -The facility maintains copies of signed reports on file for at least one year. B. Procedures for implementation of the facility's policies and procedures - pharmacist, DON, and medical provider expectations 1. The CP was interviewed on 4/24/24 at 2:29 p.m. and again at 4:59 p.m. about the procedures for facility access to MRR recommendations. The CP said she sends the MRR recommendations through the facility's computer portal to the DON directly. She said the DON was shown how to use the portal to access pharmacy recommendations by the pharmaceutical provider's account manager and by her in February 2024. 2. The DON was interviewed on 4/25/24 at 12:44 p.m. about the procedures for accessing and distributing MRR recommendations to medical providers for review and response. The DON said the CP reviewed the residents' medications monthly, created a report with medication recommendations, and sent the report through the facility computer portal. The DON said the pharmacist sent an email once she had completed her recommendations. The DON then retrieved the recommendations from the computer portal. She said it was her responsibility to print the report with the CP's recommendations and to distribute it to the appropriate medical provider. The DON said after the medical provider reviewed and responded to the recommendations, she was responsible for returning the MRR with responses to the CP. She said she printed a copy of the report which she kept in a binder in her office. 3. A medical provider was interviewed on 4/25/24 at 4:36 p.m. about the system for review and response to MRR recommendations. The provider said the process when receiving MRR recommendations was to review the resident's history, recommendations for GDRs, indications for psychotropic medications, and to pay special attention to anyone who was on long-term psychotropic medication. He said the medical provider who was on site making rounds was responsible for checking for MRR reports that were left in the provider mailbox. He said the medical providers check the box on Mondays and Fridays and they usually received MRRs monthly. He said medical providers also included physician assistants and nurse practitioners who made rounds and who were responsible for checking for MRRs. The recommendations were responded to while the medical provider was on site unless it was a more complex recommendation. In that case, the MRR report was put back in the mailbox. If it was a critical recommendation, it was returned to the DON. III. Interview with the CP and review of a summary report by the pharmaceutical company of the number of MRRs sent to the facility in 2024, revealed the facility's policy and procedures failed to ensure potential irregularities identified in MRRs as recommendations would be timely reviewed and acted upon by the medical provider, medical director, and the DON. A. CP interview The CP was interviewed on 4/24/24 at 2:29 p.m. and 4:59 p.m. She said it had been a struggle, a delay, in getting responses to MMR recommendations back from the facility. She said she had not received responses from the facility to her medication recommendations for four months. She said most of the recommendations from December 2023 had yet to be returned and, that she had not received any of the more recent, January 2024 to April 2024, recommendations back that confirmed the medical provider had reviewed and responded to the recommendations in the MRR. She stated review and responses to the recommendations in the MRR were not only for compliance with regulatory requirements but also to ensure the safety of the residents, the efficacy of the medications, preventing falls, death, and bleeding, as well as recognizing and reducing polypharmacy. B. Review of MRR summary report. A review on 4/25/24 of an executive summary report by the pharmaceutical company revealed multiple MRR recommendations in January 2024 (163), February 2024 (143), March 2024 (131), and April 2024 (138) that had not been returned to the CP to show they had been reviewed and responded to by the medical provider. III. A review of MRRs for Residents #51, #15, #60, and #64 provided by the DON on 4/24/24 at 2:00 p.m., confirmed the facility's policy and procedures failed to ensure potential irregularities and recommendations identified in MRRs would be timely reviewed and acted upon by the medical provider, medical director, and the DON. A. Resident #51 1. Resident status Resident #51, age [AGE], was admitted on [DATE]. According to the April computerized physician orders (CPO), the resident's diagnoses included right hemiarthroplasty for a right hip fracture, and Alzheimer's disease and dementia without behavioral, psychotic, or mood disturbance. The 3/22/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of three out of 15. He required substantial/maximal assistance with toileting, bed mobility, transfers, and supervision with eating and personal hygiene. The MDS documented the resident did not have physical or verbal behaviors or psychosis symptoms including hallucinations or delusions. A comprehensive review of Resident #51's behavioral monitoring from 3/22/24 to 4/25/24 revealed the resident did not have verbal or physical behaviors. A review of the resident's care plans revealed in part, plans for mood, antipsychotic medication, anticoagulant medication, and falls. The mood care plan, initiated on 3/22/24 and revised on 4/5/24, indicated Resident #51 had a history of depression and was currently taking an antidepressant and displayed minimal to no signs/symptoms of a depressed mood. Interventions included to administer psychiatric medications as ordered, monitor signs/symptoms of depression, notification of social work or physician of a decline, and psychiatric services as needed. The antipsychotic medication care plan, initiated on 3/18/24, indicated Resident #51 currently was prescribed an antipsychotic medication for dementia. Interventions included to administer medications as ordered, monitor for adverse side effects, monitor for changes in mood or behavior, monitor for falls, and psychiatric evaluation and services as needed. The anticoagulant care plan, initiated on 3/18/24, indicated Resident #51 was on an anticoagulant for a diagnosis of deep vein thrombosis (blood clot) prophylaxis. Interventions included to administer medications as ordered, monitor signs and symptoms of bleeding, monitor labs as ordered. The fall care plan, initiated on 3/15/24 and revised on 3/18/24, read Resident #51 was at risk for falls. Interventions included to anticipate needs, assist with activities of daily living (ADL), encourage the use of the call light, ensure wearing of appropriate footwear, fall mat, place in line of sight in common areas, high/low bed, orient, and physical and occupational therapy. A review of post-fall assessments dated 3/20/24, 4/3/24. 4/17/24 and 4/20/24 revealed four falls without injury. A review of the April CPO revealed the resident's medications included: -An order for Risperdal (an antipsychotic) 0.25 milligrams (mg) by mouth once a day for Alzheimer's disease, ordered on 3/15/24 and discontinued on 3/18/24. -An order for Risperdal 0.25 mg by mouth once a day in the evening, ordered on 3/20/24. -An order for Aspirin 81 mg once a day for prophylaxis, ordered on 3/16/24. -An order for Clopidogrel (Plavix), an antiplatelet blood thinner, 75 mg once a day for fracture, ordered on 3/16/24. 2. MRR review a. MRRs 3/20, 3/22, and 4/10/24 with multiple recommendations The 3/20/24 MRR documented three recommendations. -Resident #51 was receiving aspirin and Plavix daily; this was not recommended unless the resident had a recent stent in the past six months. If no recent stent, consider discontinuing one of the medications. -Recommended labs: CMP, CBC, HgA1c, TSH (thyroid stimulating hormone), and lipid panel. -Recommended to consider lowering the dose of Risperdal due to the concurrent use with fluoxetine (an antidepressant) which can increase the risk of central nervous system depression (decreased neurological function including decreased breathing, heart rate, and consciousness) and psychomotor impairment (decreased muscular coordination and function). The 3/22/24 MRR documented four recommendations. -Recommended monitoring pain levels and effectiveness while Resident #51 was on pain medications whether as needed or routine and monitor for side effects. -Recommended to clarify the diagnosis of use of aspirin, recommended discontinuing it if it was for primary prevention due to the increased risk of major bleeding in older age. -Recommended clarifying the diagnosis in Resident #51's diagnosis list for Risperidone (Risperdal) and Plavix. -Recommended adding monthly fasting blood glucose levels or a quarterly HgA1c while Resident #51 was on a Risperdal. The 4/10/24 MRR documented one recommendation. -Recommended that Alzheimer's was not an appropriate indication for Risperdal without behaviors and to update the diagnosis and order directions. b. Lack of documentation to show review and response to the MRR recommendation by the medical provider, the medical director, and the DON. A comprehensive review of Resident #51's electronic medical record (EMR) and MRRs above on 4/24/24, revealed no documentation that the above recommendations had been reviewed and acted upon by the medical provider, the medical director, and DON prior to 4/25/24, during the survey.C. Resident #60 1. Resident status Resident #60, age [AGE], was admitted to the facility on [DATE] and readmitted on [DATE]. According to the April 2024 CPO, diagnoses included severe persistent asthma, chronic respiratory failure with hypoxia (low oxygen), visual loss in both eyes, morbid obesity, chronic pain, anxiety disorder, depression, and muscle weakness. The 8/23/23 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident required extensive assistance from one person with dressing, bathing, locomotion while in the wheelchair, and extensive assistance from one to two people for bed mobility, toileting, and transfers. A review of the resident's care plan revealed plans for antidepressant medication and bleeding. The care plan for antidepressant medication documented the resident was prescribed antidepressant medication for a diagnosis of depression and anxiety. Interventions included to administer medications as ordered, monitor for adverse effects of usage, monitor for changes in mood or behavior, monitor for falls and psychiatric evaluation and services as needed or scheduled. The care plan for bleeding documented that the resident was at risk for bleeding due to taking an anticoagulant medication for coronary artery disease. Interventions included to administer medications as ordered, and monitor for discolored urine, black tarry stools, sudden severe headache, and nausea and vomiting. 2. MRR review a. MRRs dated 11/10/23, 12/14/23, 2/15/24 and 3/21/24 - with recommendations The MRR for 11/10/23 documented Resident #60 was receiving aspirin 81 mg and Plavix 75 mg. The pharmacist documented a recommendation for discontinuation of one of these medications as well as a GDR for Sertraline, an antidepressant medication. The MRR for 12/14/23 recommended a GDR of Duloxetine, an antidepressant medication The MRR for 2/15/24 documented inquiries for regarding Sertraline and Duloxetine, as well as aspirin and Plavix. The MRR for 3/21/24 recommended a GDR for Sertraline and Duloxetine. b. Lack of documentation to show review and response to the MRR recommendation by the medical provider, the medical director, or the DON. A comprehensive review of Resident #60's electronic medical record (EMR) and MRRs above on 4/24/24 revealed no documentation that the above recommendations had been reviewed and acted upon by the medical provider, the medical director, and DON prior to 4/25/24, during the survey. D. Resident #64 1. Resident status Resident #64, over age [AGE], was admitted to the facility on [DATE] and readmitted on [DATE]. According to the April CPO diagnoses included a history of falling, long-term use of anticoagulant, fracture of the neck of the right femur, atrial fibrillation, chronic congestive heart failure, peripheral vascular disease (narrow blood vessels in the limbs) and myocardial infarction (heart attack). According to the 2/19/24 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The resident required supervision for oral hygiene, rolling from side to side, and moving from sitting to lying in bed. The resident required partial assistance with upper body dressing, bed-to-chair transfers, toilet transfers, and maximal assistance for toileting hygiene and lower body dressing. The care plan for bleeding documented that the resident was at risk for bleeding due to taking an anticoagulant. Interventions included to administer medication as ordered, monitor for discolored urine black tarry stools, severe headache, nausea, and vomiting, monitor labs, and notify the provider with any concerns. The order detail dated 2/19/24 at 4:10 p.m. documented an order summary of Apixaban, an anticoagulant, one tablet by mouth every day and evening shift for status post hip surgery. 2. MRR review a. A 3/22/24 MMR documented the anticoagulant Eliquis (Apixaban) did not have the correct diagnosis listed in the resident's diagnosis list. b. Lack of documentation to show review and response to the MRR recommendation by the medical provider, the medical director, or the DON. A comprehensive review of Resident #64's electronic medical record (EMR) and MRR above on 4/24/24 revealed no documentation that the inquiry about the diagnosis for Eliquis had been reviewed and acted upon by the medical provider, the medical director, or the DON prior to 4/25/24, during the survey. IV. Facility failure to timely address the facility's known failure to ensure medical providers, the medical director, and the DON reviewed the monthly MRRs and responded to recommendations timely The NHA, interviewed on 4/25/24 at 4:33 p.m., said he was not aware until 4/24/24 (during the survey) that after receiving MRR recommendations from the CP, the recommendations were processed and provided to medical providers. A medical provider, interviewed on 4/25/24 at 4:36 p.m., said he was not aware MRRs had not been given to him by the DON since January 2024. -However, interviews with the CP revealed leadership had been informed multiple times of the facility's failure to review and respond to MRR recommendations timely. Further, the DON, who was directly involved in implementing the facility's policies and procedures to ensure timely review and response to MRR recommendations, was aware. Yet, there was no evidence steps were taken to correct the problem until 4/25/24, during the survey, when the NHA was notified the failure created a situation of immediate jeopardy with the potential for serious harm. A. Interview with the CP The CP was interviewed on 4/24/24 at 2:29 p.m. and 4:59 p.m. She said the facility leadership was aware of the problem with MRR reviews and responses. She said she brought it up every month, stating she had informed the medical director, as well as another physician who was very involved and who attended the psychotropic/GDR meetings that she was not receiving any MRR recommendations back from the facility. She also said she informed the DON and the NHA, in person, during each psychotropic/GDR meeting of this, and the DON told her they were working on it. She said she sent an email on 4/10/24, again asking about responses to MRR recommendations and noting the importance of having the recommendations completed. She stated the review and response to the recommendations in the MRR were not only for compliance with regulatory requirements but also to ensure the safety of the residents. B. Interview with the DON The DON was interviewed on 4/24/24 at 12:44 p.m. The DON said after a medical provider had reviewed and responded to the recommendations in the MRR, she sent the MRR report back to the CP through the portal. She also printed a copy of the report and placed it in a binder in her office. The DON said there was not a binder for 2024 because one had not been started. On 4/24/24 at approximately 2:00 p.m., the DON delivered the pharmacy recommendation binder for July 2023 to December 2023. The DON, NHA, and infection preventionist agreed the facility did not have a binder for pharmacy recommendations in 2024. V. Facility follow-up after survey exit 4/26/24. The NHA emailed information on 4/29/24 at 4:12 p.m., addressing Residents #51, #15, #60, and #64, and a letter from the pharmaceutical company explaining the number of MRRs sent to the facility in 2024. A. Regarding the pharmaceutical company letter (undated) explaining the number of MRRs sent to the facility in 2024. The letter read that the number of recommendations on the executive summ[TRUNCATED]