The facility reported a census of 16 residents. The sample included eight residents. Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to two of three residents reviewed, Resident (R) 3 and R11. Findings included: - On 02/26/25 review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-10055 (SNF ABN- the waiver issued by providers when the services might not be covered) and the Notification of Medicare Non-Coverage Form 10123 (NOMNC- the form used to notify Medicare A participants of their rights to appeal and the last covered date of service) for three residents. R3 and R11 lacked the SNF ABN form, which is a requirement when discharging from skilled services, with days remaining, and remaining in the facility. The Beneficiary Notice documented R3's skilled discharge date as 05/22/24 and would remain in the facility. R11's skilled discharge date as 05/22/24 and would remain in the facility. R3's Skilled Nursing Beneficiary Protection Notification Review documented R3's start date of skilled services as 04/06/24 and end date of 05/22/24. R3 received only the NOMNC form signed on 05/17/24. R11's Skilled Nursing Beneficiary Protection Notification Review documented R11's start date of skilled services as 03/29/24 and end date of 05/22/24. R11 received only the NOMNC form signed on 05/17/24. On 02/26/25 at 09:03 AM, Administrative Staff A revealed she did not know they had to use both forms, confirmed that both forms should have been given as required. Administrative Staff A stated she did not know they were to use both forms. The NOMNC was easier for residents to understand. The facility's policy Right to be Informed of Professional and Financial Information dated 05/15/23, documented the facility would provide a notice of rights and services to each resident prior to or admission and during the resident's stay. The facility will provide the resident with the State-Developed notice of Medicaid rights and obligations. The facility will inform each Medicaid-eligible resident, in writing, at the time of admission to the facility and when the resident becomes eligible for Medicaid and of the changes in services or new charges. The facility failed to ensure the correct and complete Beneficiary Protection Notification forms (SNF ABN 10055) were issued to R3 and R11, as required.

The facility reported a census of 16 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food to prevent possible food-borne illness among the facility's residents. Findings included: On 02/24/25 at 10:58 AM, during an initial tour of the central kitchen and refrigerator storage areas with Dietary Staff BB, the following areas of concern were identified: One unsealed bag of broccoli, and a container of ranch dressing, in the refrigerator. One sealed bag of onion rings, three bags of hamburger buns, and a bag of hotdog buns without a date or label in the freezer. There was one cutting board with uncleanable surfaces that were discolored along with deep slices that were visible. On 02/24/25 at 11:15 AM, an interview with Dietary Manager BB revealed she expected staff to date opened food items. Dietary Manager BB stated that the above concerns identified with kitchen and freezer storage, which included undated and unsealed items, were unacceptable. The facility's policy on Dietary Purchase, Receipt, and Storage, dated 02/07/17, requires that all products be clearly labeled with the date of receipt. Staff must ensure that food items are rotated to use the oldest products first. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility reported a census of 14 residents and identified 1 with cognitive impairment and self-mobile. Based on interview, observation and record review the facility failed to ensure a safe environment for the one resident with the failure to secure hazardous chemicals in the facility's beauty shop. Findings include: - On 05/09/23 at 07:30 AM, observation of the facility beauty shop revealed two containers of hair spray unsecured. The hair spray bottles revealed warning labels to keep out of reach of children. On 05/09/23 at 08:00 AM, with notification to Maintenance Staff U of the unlocked chemicals, revealed the hair spray should be secured in a locked cabinet. On 05/10/23 at 12:57 PM, Licensed Nurse G reported that all chemicals in the building needed to be locked inside a cabinet. On 05/10/23 at 12:33 PM, Administrative Nurse D reported all chemicals should be locked inside a cabinet when not in use. The facility's Control of Hazardous Chemicals policy, dated 05/12/21 documented that all substances with warning labels, including but not limited to keep out of reach of children were to Always be locked at all times to avoid accessibility of any elder in the facility. The facility failed to ensure a safe environment for the one resident of the facility with cognitive impairment and self-mobile, related to accident hazards of unsecured chemicals in the facility's beauty shop.

The facility census totaled 14 residents with seven residents residing on hall 100, and one bath house used to bathe those seven residents on that hall. Based on observation, interview, and record review the facility failed to ensure call light accessibility to these seven residents when they received showers in this one bath house. The shower area lacked a cord on the call light located next to the shower making it inaccessible to residents receiving showers and staff providing showers, in case of emergency. Findings include: - Tour of the facility on 05/09/23 at 07:30 AM, revealed a shower room on the hall 100. While checking the room there was a call light box on the wall next to the shower with no pull cord attached for residents or staff to use in case of an emergency. Interview on 05/09/23 at 08:00 AM, Maintenance staff U reported he was aware of the cord being gone and was told about it several days ago, but just had not gotten around to replacing it yet. On 05/10/23 at 12:33 PM administrative staff A reported she was surprised about the cord. She thought she had taken care of that last week but would make sure it was corrected. Review of the facility policy named Nurse Alert System dated 01/17/23 revealed the facility was equipped with a call light system that included a wireless pager system. When the system is activated by an elder, an alert is sent to the pagers of the Direct Care Staff until it is answered and cleared. The nurse call system will be checked, and checks documented by the Environmental Services Staff on a routine basis. The facility failed to ensure call light accessibility to these seven residents when they received showers in this one bath house. The shower area lacked a cord on the call light located next to the shower making it inaccessible to residents receiving showers and staff providing showers, in case of emergency.

The facility census totaled 15 residents with eight included in the sample. Based on observation, interview, and record review the facility failed to remove expired medications from the refrigerator to include two single dose vaccination injections: one Influenza vaccine (flu vaccine) with an expiration date 06/30/21 and one single dose injection Pneumococcal-13 (pneumonia vaccine) with an expiration date 07/21. Findings included: - Observation of the Medication Room on 08/25/21 at 11:31 AM revealed the refrigerator contained two expired injectable vaccinations. A single dose of Influenza vaccine with the expiration date of 06/30/21 and a single dose of Pneumococcal-13 vaccine with the expiration date of 07/21 Interview with Licensed Nurse (LN) E on 08/30/21 at 09:28 AM revealed the medication room should be check weekly for expired medication by the night nurse. Interview with Administrative Nurse D on 08/30/21 at 10:52 AM revealed she expected the nursing staff to remove medications when expired. The facility policy Medication Labeling and Storage dated 09/18/19 lacked information regarding the disposal of expired medications. The facility failed to remove two expired injectable vaccinations from the medication room refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R4's diagnoses from the Physician's Order dated 05/01/21 revealed the following : major depressive disorder recurrent severe with psychotic symptoms (major mood disorder), schizoaffective disorder bipolar type (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and traumatic brain injury (A head injury causing damage to the brain). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The resident had a mood severity score of two for mood at a two, not indicative of depression. R4 received antipsychotic, antidepressant, and hypnotic medications daily during the seven day look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/09/20 revealed R4 received antipsychotic medications for control of behaviors due to psychotic diagnosis. The Care Plan dated 06/25/21 revealed R 4 was at risk for a decline in psychosocial well being due to psychotropic medications and history of traumatic brain injury. Current medications included Pristiq (antidepressant) and Risperdal (treat schizophrenia, bipolar). The Pharmacy Medication Recommendation dated 12/22/20 revealed a recommendation that R4 was due for a dose reduction on the medication Pristiq 50 milligrams (mg) since November 2019. R4 would be a good candidate to decrease this medication to 25 mg at this time. The Electronic Medical Record from 12/20/20 to 08/26/21 revealed the medication Pristiq 50 mg continued without a dose reduction attempted. Observation of R4 on 08/25/21 at 11:46 AM in the dining room for lunch sits by himself if questions are asked by the staff R4 will give short answers no abnormal mouth movement or abnormal hand movements noted. Observed R4 08/25/21 at 03:16 PM going outside to smoke accompanied by a staff member returned inside facility at 3:22 PM went straight to his room and shut the door no behaviors noted. Observed R4 08/26/21 at 08:27 AM in dining room for breakfast sits by himself does not socialize with the staff or other residents no behaviors noted. Interview with Pharmacist F on 08/30/21 at 11:30 AM revealed she sends the recommendations to the physician and if no response will continue the dose, but would leave recommendations for the facility to fax if no changes in one month. She would make another recommendation in six months if still no response. Interview with Administrative Nurse D on 08/30/21 at 11:45 AM revealed the pharmacist sent the recommendations to the Director of Nursing and the physician to be followed up with in 48 to 72 hours and if still no response, would contact the physician office for completion. The facility policy Drug Regimen Review dated 02/20/17 revealed the consultant pharmacist will perform a drug regimen review on each elder living in this facility at the time of the elder's admission to the facility and at least monthly and when requested by team members of the facility, but no longer than every six months. The Director of Nursing will track physician response reports and if no response within five working days the or designee would place a phone call to the physician for a phone order response. If no response from the physician within 10 days working days, the facility's Medical Director would be contacted for requested response/recommendations. All responses would be documented in the elder's clinical record. The facility failed to follow-up on a pharmacist recommendation for a dose reduction for Pristiq for R4. - R14's Physician Orders dated 06/15/21 revealed a diagnosis of major depressive disorder (a mood disorder). The Annual Minimum Date Set dated 07/22/21 revealed a Brief Interview for Mental Status score of 15 indicating intact cognition. R14 received daily antidepressant medications during the seven-day look back period. The Physician Orders dated 08/26/21 included an order for Effexor XR (extended release) 75 milligrams (mg) daily for major depressive disorder with a start date of 01/29/21. The Pharmacy Reviews dated 07/22/21 included a pharmacist recommendation R14 would be a good candidate for decreasing the dosage of Effexor 75 mg, R14 received since 01/29/21, at this time. Observed R14 on 08/25/21 at 08:15 AM ambulating with walker in the hallway smiling and laughing with the staff. Interview with Pharmacist F on 08/30/21 at 11:30 AM revealed she sends the recommendations to the physician and if no response will continue the dose, but would leave recommendations for the facility to fax if no changes in one month. She would make another recommendation in six months if still no response. Interview with Administrative Nurse D on 08/30/21 at 11:45 AM revealed the pharmacist sent the recommendations to the Director of Nursing and the physician to be followed up with in 48 to 72 hours and if still no response would contact the physician office for completion. The facility policy dated 02/20/17 revealed the consultant pharmacist will perform a drug regimen review on each elder living in this facility at the time of the elder's admission to the facility and at least monthly and when physician for a phone order response. If no response from the physician within 10 days working days, the facility's Medical Director would be contacted for requested response/recommendations. All responses would be documented in the elder's clinical record. The facility failed to follow-up on a pharmacist recommendation for a dose reduction for Effexor for R14. The facility reported a census of 15 residents, with eight residents included in the sample, and five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow-up on the recommendations made by the pharmacist for Resident (R)1, R4, R7 and R14 medications. Findings included: - The August 2021 Physician Order Summary revealed R1 with the following diagnoses: anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), pain, irritability and anger, and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness.) The Annual Minimum Data Set (MDS) dated [DATE] revealed R1 was rarely or never understood, a Brief Interview for Mental Status (BIMS) score could not be completed, and noted R1 as moderately impaired for cognitive skills for daily decision-making. R1 received an antipsychotic, antianxiety, and an antidepressant medication daily in the seven-day review period. The Quarterly MDS dated 07/02/21 revealed R1 was rarely or never understood. A BIMS could not be completed and R1 was moderately impaired for cognitive skills for daily decision-making. R1 received daily antipsychotic, antianxiety, and an antidepressant medication. The Cognitive Loss/Dementia Care Area Assessment (CAA) revealed due to traumatic head injury R1 required assistance with all decision-making processes. Review of the Psychotropic Drug Use Care Area Assessment (CAA) dated 10/01/20 revealed R1 with a diagnosis of anxiety. He would at times refuse care by trying to hit staff and making an angry face. R1 received psychotropic medications for depression, anxiety, irritability, and anger. Review of the Care Plan revealed R1 received Zoloft (an antidepressant medication also known as Sertraline) for depression. Review of the Physician Order dated 11/27/19 revealed R1 received Zoloft (an antidepressant medication) 100 milligrams (mg), one tablet through a G-Tube (a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids) daily for major depressive disorder. Review of the monthly pharmacist Medication Regimen Review (MMR) revealed the pharmacist recommended a GDR be completed for Sertraline (Zoloft) during the months of 07/20, 01/21, 02/21 and 07/21. Review of the R1's Electronic Health Record (EHR) from 07/20 to present revealed no evidence of an attempted GDR or physician response. An observation on 08/25/21 at 10:42 AM revealed R1 sat in a wheeled recliner in the living room and the staff played a radio for him and then pushed R1 around to the various staff offices to say hello. R1 had a smile on his face and did not exhibit any negative behaviors. During an interview on 08/25/21 at 01:49 PM, Certified Nurse Aide (CNA) C stated R1 did not exhibit any negative behaviors towards staff. During an interview on 08/30/21 at 10:40 AM, Licensed Nurse (LN) E stated R1 exhibited negative behaviors like swatting at staff. During an interview on 08/30/21 at 11:40 AM, Administrative Nurse D confirmed the recommended GDRs were not completed for R1. Administrative Nurse D stated the pharmacist sent all GDR requests to the physicians. Administrative Nurse D stated she sent faxes to the physicians to follow-up on pharmacist recommendations and stated she expected the physicians to respond to the GDR request within 48-72 hours. Administrative Nurse D stated if she did not get a response from the physician, she would call them. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure the physician responded to a GDR recommendation concerning Sertraline (Zoloft) for R1. - Review of the August 2021 Physician Order Summary revealed R7 had a diagnosis of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R7 had a total mood severity score of three, which indicated minimal depression and received an antidepressant daily. The Quarterly MDS dated 06/17/21 revealed a BIMS score of nine, indicating moderate cognitive impairment. R7 had a total mood severity score of two, which indicated minimal depression and received an antidepressant daily. Review of the Psychotropic Drug Use Care Area Assessment (CAA) dated 03/18/21 revealed R7 was medicated with psychotropic medications for multiple psychiatric diagnosis. The consultant pharmacist was to review medications and initiate gradual dose reductions to the Primary Care Physician (PCP). The Care Plan dated 10/21/18 revealed R7 used psychotropic medications and Lexapro for depression. Review of the Physician Order dated 11/26/19 revealed R7 received, Escitalopram (antidepressant medication also known as Lexapro) 20 milligrams (mg), one tablet, by mouth daily for major depressive disorder. Review of the pharmacist Medication Regimen Review (MMR) dated 10/18/20 revealed the pharmacist recommended a GDR be completed for Escitalopram from 20 mg to 10 mg. Review of the R7's Electronic Health Record (EHR) revealed no evidence of an attempted GDR or physician response. An observation on 08/25/21 at 08:48 AM revealed R7 sat in her wheelchair in the dining room for breakfast. R7 was alert and did not appear sedated and did not exhibit any negative behaviors. During an interview on 08/25/21 at 01:47 PM, Certified Nurse Aide (CNA) C stated R7 has never exhibited any negative behaviors towards staff or other residents. During an interview on 08/30/21 at 10:34 AM, Licensed Nurse (LN) E stated R7 did not appear to be depressed. During an interview on 08/30/21 at 11:40 AM, Administrative Nurse D confirmed the recommended GDR for Lexapro was not completed for R7. Administrative Nurse D stated the pharmacist sent all GDR requests to the physicians. Administrative Nurse D stated she sent faxes to the physicians to follow-up on pharmacist recommendations and stated she expected the physicians to respond to the GDR request within 48-72 hours. Administrative Nurse D stated if she did not get a response from the physician, she would call them. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure the physician responded to a GDR recommendation concerning Escitalopram for R7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R4's diagnoses from the Physician's Order dated 05/01/21 revealed the following: major depressive disorder recurrent severe with psychotic symptoms (major mood disorder), schizoaffective disorder bipolar type (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) and traumatic brain injury (A head injury causing damage to the brain). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of nine indicating moderate cognitive impairment. The resident had a mood severity score of two for mood at a two, not indicative of depression. R4 received antipsychotic, antidepressant, and hypnotic medications daily during the seven day look back period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/09/20 revealed R4 received antipsychotic medications for control of behaviors due to psychotic diagnosis. The Care Plan dated 06/25/21 revealed R4 was at risk for a decline in psychosocial well being due to psychotropic medications and history of traumatic brain injury. Current medications included Pristiq (antidepressant) and Risperdal (treat schizophrenia, bipolar). The Pharmacy Medication Recommendation dated 12/22/20 revealed a recommendation that R4 was due for a dose reduction on the medication Pristiq 50 milligrams (mg) since November 2019. R4 would be a good candidate to decrease this medication to 25 mg at this time. The Electronic Medical Record from 12/20/20 to 08/26/21 revealed the medication Pristiq 50 mg continued without a dose reduction attempted. Observation of R4 on 08/25/21 at 11:46 AM in the dining room for lunch sits by himself if questions are asked by the staff R4 will give short answers no abnormal mouth movement or abnormal hand movements noted. Observed R4 08/25/21 at 03:16 PM going outside to smoke accompanied by a staff member and then R4 returned inside facility at 03:22 PM and went straight to his room, shut the door, with no behaviors noted. Observed R4 08/26/21 at 08:27 AM sat in dining room for breakfast by himself and did not socialize with the staff or other residents. Interview with Pharmacist F on 08/30/21 at 11:30 AM revealed she sends the recommendations to the physician and if no response will continue the dose, but would leave recommendations for the facility to fax if no changes in one month. She would make another recommendation in six months if still no response. Interview with Administrative Nurse D on 08/30/21 at 11:45 AM revealed the pharmacist sent the recommendations to the Director of Nursing and the physician to be followed up with in 48 to 72 hours and if still no response, would contact the physician office for completion. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure R4 did not recieve unecessary medications when the facility follow-up on a pharmacist recommendation for a dose reduction of Pristiq for R4. - R14's diagnosis from the Physician Orders dated 06/15/21 revealed a diagnosis of major depressive disorder (a mood disorder). The Annual Minimum Date Set dated 07/22/21 revealed a Brief Interview for Mental Status score of 15 indicating intact cognition. Review of the medication section revealed R14 received 7 days of antidepressant during the look back period. The Physician Orders dated 08/26/21 included an order for Effexor XR (extended release) 75 milligrams (mg) daily for major depressive disorder with a start date of 01/29/21. The Pharmacy Reviews dated 07/22/21 included a pharmacist recommendation R14 received Effexor 75 mg since 01/29/21 and would be a good candidate to decrease the dose at this time. Review of the R14's Electronic Health Record (EHR) from 07/22/21-08/30/21 revealed no evidence of an attempted decrease in Effexor dosage. Observed R14 on 08/25/21 at 08:15 AM ambulating with walker in the hallway smiling and laughing with the staff. Interview with Pharmacist F on 08/30/21 at 11:30 AM revealed she sends the recommendations to the physician and if no response will continue the dose, but would leave recommendations for the facility to fax if no changes in one month. She would make another recommendation in six months if still no response. Interview with Administrative Nurse D on 08/30/21 at 11:45 AM revealed the pharmacist sent the recommendations to the Director of Nursing and the physician to be followed up with in 48 to 72 hours and if still no response would contact the physician office for completion. The facility policy dated 02/20/17 revealed the consultant pharmacist will perform a drug regimen review on each elder living in this facility at the time of the elder's admission to the facility and at least monthly and when physician for a phone order response. If no response from the physician within 10 days working days, the facility's Medical Director would be contacted for requested response/recommendations. All responses would be documented in the elder's clinical record. The facility failed to ensure R14 did not receive unecessary medications when the facility did not follow-up on a pharmacist recommendation for a dose reduction for Effexor for R14. The facility had a census of 15 residents with eight residents in the sample and five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure four of five residents did not receive unnecessary medications when the facility failed to ensure the physician responded to a Gradual Dose Reduction (GDR) recommendation to be completed on psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) for Residents (R)1, R4, R7 and R14. Findings included: - Review of the August 2021 Physician Order Summary revealed R1 had the following diagnoses: anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), pain, irritability and anger, and major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness.) The Annual Minimum Data Set (MDS) dated [DATE] revealed R1 was rarely or never understood. A Brief Interview for Mental Status (BIMS) score could not be completed and noted R1 as moderately impaired for cognitive skills for daily decision-making. R1 received an antipsychotic, antianxiety, and an antidepressant medication daily in the seven-day review period. The Quarterly MDS dated 07/02/21 revealed R1 was rarely or never understood. A BIMS could not be completed and R1 was moderately impaired for cognitive skills for daily decision-making. R1 received daily antipsychotic, antianxiety, and an antidepressant medication. The Cognitive Loss/Dementia Care Area Assessment (CAA) revealed due to traumatic head injury R1 required assistance with all decision-making processes. Review of the Psychotropic Drug Use Care Area Assessment (CAA) dated 10/01/20 revealed R1 had a diagnosis of anxiety. He would at times refuse care by trying to hit staff and making an angry face. R1 received psychotropic medications for depression, anxiety, irritability, and anger. Review of the Care Plan revealed R1 received Zoloft (an antidepressant medication also known as Sertraline) for depression. Review of the Physician Order dated 11/27/19 revealed R1 received Zoloft (an antidepressant medication) 100 milligrams (mg), one tablet through a G-Tube (a tube inserted through the wall of the abdomen directly into the stomach. It allows air and fluid to leave the stomach and can be used to give drugs and liquids) daily for major depressive disorder. Review of the monthly pharmacist Medication Regimen Review (MMR) revealed the pharmacist recommended a GDR be completed for Sertraline (Zoloft) during the months of 07/20, 01/21, 02/21 and 07/21. Review of the R1's Electronic Health Record (EHR) from 07/20 to present revealed no evidence of an attempted GDR or physician response. An observation on 08/25/21 at 10:42 AM revealed R1 sat in a wheeled recliner in the living room and the staff played a radio for him and then pushed R1 around to the various staff offices to say hello. R1 had a smile on his face and did not exhibit any negative behaviors. During an interview on 08/25/21 at 01:49 PM, Certified Nurse Aide (CNA) C stated R1 did not exhibit any negative behaviors towards staff. During an interview on 08/30/21 at 10:40 AM, Licensed Nurse (LN) E stated R1 exhibited negative behaviors like swatting at staff. During an interview on 08/30/21 at 11:40 AM, Administrative Nurse D confirmed the recommended GDRs were not completed for R1. Administrative Nurse D stated the pharmacist sent all GDR requests to the physicians. Administrative Nurse D stated she sent faxes to the physicians to follow-up on pharmacist recommendations and stated she expected the physicians to respond to the GDR request within 48-72 hours. Administrative Nurse D stated if she did not get a response from the physician, she would call them. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure the physician responded to a GDR recommendation concerning Sertraline (Zoloft) for R1. - Review of the August 2021 Physician Order Summary revealed R7 had a diagnosis of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. R7 had a total mood severity score of three, which indicated minimal depression and received an antidepressant daily. The Quarterly MDS dated 06/17/21 revealed a BIMS score of nine, indicating moderate cognitive impairment. R7 had a total mood severity score of two, which indicated minimal depression and received an antidepressant daily. Review of the Psychotropic Drug Use Care Area Assessment (CAA) dated 03/18/21 revealed R7 was medicated with psychotropic medications for multiple psychiatric diagnosis. The consultant pharmacist was to review medications and initiate gradual dose reductions to the Primary Care Physician (PCP). The Care Plan dated 10/21/18 revealed R7 used psychotropic medications and Lexapro for depression. Review of the Physician Order dated 11/26/19 revealed R7 received, Escitalopram (antidepressant medication also known as Lexapro) 20 milligrams (mg), one tablet, by mouth daily for major depressive disorder. Review of the pharmacist Medication Regimen Review (MMR) dated 10/18/20 revealed the pharmacist recommended a GDR be completed for Escitalopram from 20 mg to 10 mg. Review of the R7's Electronic Health Record (EHR) revealed no evidence of an attempted GDR or physician response. An observation on 08/25/21 at 08:48 AM revealed R7 sat in her wheelchair in the dining room for breakfast. R7 was alert and did not appear sedated and did not exhibit any negative behaviors. During an interview on 08/25/21 at 01:47 PM, Certified Nurse Aide (CNA) C stated R7 has never exhibited any negative behaviors towards staff or other residents. During an interview on 08/30/21 at 10:34 AM, Licensed Nurse (LN) E stated R7 did not appear to be depressed. During an interview on 08/30/21 at 11:40 AM, Administrative Nurse D confirmed the recommended GDR for Lexapro was not completed for R7. Administrative Nurse D stated the pharmacist sent all GDR requests to the physicians. Administrative Nurse D stated she sent faxes to the physicians to follow-up on pharmacist recommendations and stated she expected the physicians to respond to the GDR request within 48-72 hours. Administrative Nurse D stated if she did not get a response from the physician, she would call them. Review of the Drug Regimen Review policy dated 02/17/20 revealed, The consultant pharmacist would perform a drug regimen on each elder .All medication orders would be reviewed for .Need for gradual dose reduction based on manufacturer's recommendations and regulatory requirements. The facility failed to ensure the physician responded to a GDR recommendation concerning Escitalopram for R7.