**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based records reviewed and interviews for one of three sampled residents (Resident #1), whose admission physician's orders included the administration of Eliquis (anticoagulant ), the Facility failed to ensure that upon completion of his/her admission Medication Regimen Review (MRR) by the Consultant Pharmacist that nursing reviewed and addressed the pharmacy recommendation related to his/her dosage of Eliquis timely, as a result for more than a month, Resident #1 was overmedicated with Eliquis, he/she experienced an acute change in medical status due to being administered excess Eliquis, and required hospital transfer with admission, where he/she received blood transfusions and additional treatments to stabilize his/her condition. Findings Include: Review of the Facility's Policy titled admission Medication Regimen Review (MRR), dated as last revised 06/01/24, indicated that an admission MRR will be performed within 72 hours of admission or an agreed upon timeframe of admission by a licensed pharmacist per authorization of the facility. Significant medication issues, considered to be time sensitive, identified by the consultant pharmacist during the admission MMR, must be communicated to the physician/prescriber or designees and resolved by 11:59 P.M. of the following day, per the IMPACT Act. The Policy further indicated the following: -Upon completion of the admission MMR, the pharmacy consultant recommendations may be made electronically or by printed copy and are submitted to the DON or designee who will notify the prescriber for review; -When a time sensitive medication issue is identified that requires immediate attention of the prescriber, the pharmacist will call the facility. Resident #1 was admitted to the Facility in April 2024, diagnoses include septic shock due to a stage IV (wound tunnels through all layers of the skin and expose bone) decubitus ulcer, sickle-cell anemia (inherited group disorder that causes blood cells to become misshapen and break down), diabetes mellitus, a deep vein thrombosis (blood clot) to both lower extremities, and a pulmonary embolism (blood clot in the lung) to his/her left lower lung. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/10/24, indicated (per the hospital discharge summary) Resident #1 was supposed to be transitioned to Eliquis 5 milligrams (mg) by mouth two times a day (for a total of 10 mg a day) upon admission to the facility, and that the Hospital discharge medication list had Eliquis 10 mg by mouth twice daily that had been reconciled (by nursing) with the physician with no stop date or clarification. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that he/she was started on Eliquis 10 mg twice daily (total of 20 mg a day), last dose to be administered on the evening of 04/11/24, and then transition resident to Eliquis 5 mg twice daily thereafter. Review of Resident #1's Facility Medication Reconciliation Form, dated 04/11/24, indicated he/she was to be administered Eliquis 5 mg, 2 tablets, (total of 10 mg) by mouth daily. However, Resident #1's order for Eliquis, as written and indicated on the Medication Reconciliation Form, was still incorrect, since the Hospital Discharge Summary indicated he/she was to be administered Eliquis 5 mg, two times a day (for a total of 10 mg a day), and not 10 mg, as a one time dose daily. Review of Resident #1's admission Physician's Orders, dated 04/11/24, indicated to administer Eliquis 5 mg, give two tablets (10 mg) by mouth two times a day for blood clots (which totaled 20 mg a day). Review of Resident #1's Pharmacy Consultation Report, dated 04/15/24, indicated it contained a time sensitive recommendation requiring a prescriber response and facility action by 11:59 P.M. on 04/16/24 per federal impact act requirements. The Consult indicated the following: Resident #1 is ordered Eliquis 10 mg twice a day for blood clots without a stop date for use (typically for 7 days acutely). The Consult further indicated to reevaluate continued use at this dose and document stop date. During a telephone interview on 7/17/24 at 10:11 A.M., and a follow-up telephone interview at 2:46 P.M., the Consultant Pharmacy Manager said the Consultant that completed Resident #1's MMR on 4/15/24, had emailed the recommendations to the Director of Nurses and 4 other designated staff members at the facility that same day. The Manager said the body of the email indicated it contained a recommendation that was time sensitive and that when they flag an email in the PCC system on their end, it is also flagged in the email on the facility end. The Manager could not explain why the Pharmacy had not conducted a follow-up to see if the recommendation had been completed. Review of Resident #1's electronic and hard copy Medical Record, indicated there was no documentation to support nursing staff addressed this time sensitive pharmacy recommendation by the Consultant with the MD or the NP. Review of Resident #1's Medication Administration Record (MAR) dated 04/15/24 to 05/28/24, indicated that despite the pharmacy recommendation to address the dosage of Eliquis, he/she was still administered 10 mg two times a day (for a total of 20 mg a day) during the above referenced time frame. On 5/29/24 Resident #1 was transferred to the Hospital Emergency Department with shortness of breath, weakness, nausea, vomiting, and critically a low Hemoglobin (Hgb, protein in red blood cells that carries oxygen) 6.4 (normal range is between 12.3 and 15.3) and critically low Hematocrit (Hct, measures the volume of red blood cells compared to the total blood volume) 19.2 (normal range is between 36-48) ) requiring blood transfusions and a spinal Arteriovenous (AV) fistula (an abnormal connection between an artery and a vein). Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she had been admitted for anemia in setting of an excessive anticoagulation dose, was found to have a spinal AV fistula, requiring blood transfusion and embolization (procedure used to block a blood vessel, used to stop bleeding). Review of Resident #1's Medication Error Report, dated 06/11/24, indicated the Unit Manager had been sent a pharmacy recommendation for his/her Eliquis on 04/15/24, that had not been completed. During an interview on 07/08/24 at 1:19 P.M., Unit Manager #1 said that on 06/11/24, the Director of Nurses (DON) informed her that the admission Medication Regimen Review (MRR) by their Pharmacy Consult which had included a recommendation regarding the dosage of Eliquis, had been completed for Resident #1 on 04/15/24, and that the recommendations had not been addressed or followed up on by nursing. The Unit Manager said that she had not remembered seeing any pharmacy recommendations for Resident #1 and said typically the pharmacy will electronically mail (e-mail) a copy of the recommendations to both the unit manager and the DON. Unit Manager #1 said that it was her responsibility to follow through with pharmacy recommendations, and said that prior to this incident there had not been a good system in place and that was why the recommendation had been missed. During an interview on 07/08/24 at 12:15 P.M., the Nurse Practitioner (NP) said typically nursing staff will leave a whole bunch of pharmacy recommendations for them to review and sign for the providers. The NP said she was unaware of Resident #1's pharmacy recommendation from 4/15/24. During a telephone interview on 07/11/24 at 10:20 A.M., the Former Director of Nurses (DON) said that she was made aware of Resident #1's 04/15/24 pharmacy recommendations that had been missed by nursing, while he/she was in the hospital after being sent out acutely for critically low blood laboratory work. The DON said typically all pharmacy recommendations are sent to the unit manager and herself for review and said that recommendations are expected to be completed in a timely manner. The DON said she was unaware of the missed recommendation until 06/10/24 when the Pharmacy sent a message stating that the 4/15/24 recommendation had not been completed. During an interview on 07/08/24 at 3:34 P.M., the Interim DON said that he had only now became aware of the missed pharmacy recommendation for Resident #1. The Interim DON said that is the Facility's expectation that all pharmacy recommendations be reviewed by nursing and completed according to the Facility policy and procedures and completed in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sample residents (Resident #1), whose Hospital Discharge Summary indicated that the daily dosage of his/her Eliquis (anticoagulant) was to be decreased from 10 milligrams (mg) two times a day, to 5 mg two times a day, the facility failed to ensure Resident #1 was free from a significant medication error when due to a medication reconciliation error upon admission by nursing, he/she continued to be administered Eliquis 10 mg two times a day for more than a month after his/her admission. Resident #1 experienced an acute change in medical status which include shortness of breath, weakness and critically low blood laboratory work related to being overmedicated with Eliquis, he/she was transferred and admitted to the Hospital where he/she required blood transfusions and additional treatment in order to stabilize his/her condition. Findings include: Review of the Facility Policy titled, Reconciliation of Medication on admission Guideline, dated 01/26/23, indicated medication reconciliation is to ensure medication safety by accurately for the resident's medications, routes and dosages upon admission or readmission to the facility. The Policy indicated the following guidelines; -Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission process; -Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and their condition; and -Medication reconciliation helps to ensure the medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/10/24, indicated (per the hospital discharge summary) Resident #1 was supposed to be transitioned to Eliquis 5 milligrams (mg) by mouth two times a day upon admission to the facility, and that the Hospital discharge medication list had Eliquis 10 mg by mouth twice daily that had been reconciled with the physician with no stop date or any additional clarification. The Report indicated that, on 05/29/24, Resident #1 was transferred to the Hospital Emergency Department secondary to weakness, nausea, vomiting, and a critically low Hemoglobin (Hgb, protein in red blood cells that carries oxygen) 6.4 (normal range is between 12.3 and 15.3) requiring transfusion of two units of blood. Resident #1 was admitted to the Facility in April 2024, diagnoses include septic shock due to a stage IV (wound tunnels through all layers of the skin and expose bone) decubitus ulcer, sickle-cell (inherited group disorders that causes blood cells to become misshapen and break down) anemia, diabetes mellitus, a deep vein thrombosis (blood clot) to both lower extremities, and a pulmonary embolism (blood clot in the lung) to his/her left lower lung. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that he/she was started on Eliquis 10 mg twice daily (total of 20 mg a day), last dose to be administered on the evening of 04/11/24, and then transition resident to Eliquis 5 mg twice daily (for a total of 10 mg a day) thereafter. Review of Resident #1's Facility Medication Reconciliation Form, dated 04/11/24, indicated he/she was to be administered Eliquis 5 mg 2 tablets by mouth daily (for a total of 10 mg a day). However, Resident #1's order for Eliquis, as written and indicated on the Medication Reconciliation Form, was still incorrect, since the Hospital Discharge Summary indicated he/she was to be administered Eliquis 5 mg, two times a day (for a total of 10 mg a day), not 10 mg as a one time dose daily. Review of Resident #1's admission Physician's Orders, dated 04/11/24, indicated to administer Eliquis 5 mg, give two tablets (10 mg) by mouth two times a day for blood clots (for a total of 20 mg a day). However, the facility's Medication Reconciliation and physicians orders, were not consistent with the Hospital Discharge Summary that indicated Resident #1 was to be transitioned to and administered Eliquis 5 mg, two times a day (for a total of 10 mg a day) after the 4/11/24 evening dose. Review of Resident #1's auto-populated Alert Order Progress Note, (generated by Point Click Care, PCC, the Facility's electronic medical record) which is auto-generated by PCC once an alert is identified regarding a physician's order, dated 04/12/24, indicated his/her Eliquis order was outside of the recommended dose or frequency; The auto-populated Alert Order Progress Note further indicated: Eliquis oral tablet 5 mg (2 tablets) by mouth two times a day for blood clots. -The daily dose of 4 tablets exceeds the usual dose of 1 to 2 tablets; and -The single dose of 2 tablets exceeds the maximum single dose of 1 tablet. The usual dose is 1 to 2 tablets. Review of Resident #1's electronic and hard copy Medical Record, indicated there was no documentation to support that nursing staff had addressed the Alert Order related to the dosage of his/her Eliquis with his/her physician or nurse practitioner. Review of Resident #1's Nurse Practitioner (NP) Progress Note, dated 04/12/24, indicated his/her current medication included Eliquis 5 mg tablet, take 2 tablets (10 mg) by mouth 2 times a day (for a total of 20 mg a day). However, this was inconsistent with the Hospital Discharge Summary that indicated Resident #1 was to be transitioned to Eliquis 5 mg, two times a day (total of 10 mg day), after receiving his/her 4/11/24 evening dose. Review of Resident #1's Physician's (MD) Progress Note, dated 04/15/24, indicated his/her current medication included Eliquis 5 mg tablet, take 2 tablets (10 mg total) by mouth 2 times a day (for a total of 20 mg a day). However, this was inconsistent with the Hospital Discharge Summary that indicated Resident #1 was to be transitioned to Eliquis 5 mg, two times a day (total of 10 mg day), after receiving his/her 4/11/24 evening dose. Review of Resident #1's Medication Administration Record (MAR), date 04/12/24 through 5/29//24, indicated he/she received Eliquis 5 mg, two tablets (10 mg) by mouth two times a day, for a total of 20 mg a day (instead of total of 10 mg a day as indicated in the Hospital Discharge Summary). Review of Resident #1's Complete Blood Counts (CBC) laboratory work, for the month of May 2024, indicated he/she had abnormal lab values that were steadily declining, which included the following: (HGB - Hemaglobin, protein in red blood cells that carry oxygen, normal range is between 12.3 and 15.3) (HCT - Hematocrit, percentage by volume of red blood cells in the blood, normal range is between 36-48) 05/01/24-HGB 9.6 and HCT 28.8 05/08/24-HGB 9.5 and HCT 28.6 05/15/24-HGB 9.0 and HCT 27.7 05/22/24-HGB 8.0 and HCT 24.1 05/29/24-HGB 6.4 and HCT 19.2 Review of Resident #1's Nurse Progress Note, dated 05/21/24, indicated he/she had a very large and bloody wound to his/her buttocks. Review of Resident #1's Nurse Progress Note, dated 05/22/24, indicated his/her buttocks wound had bloody drainage and required an abdominal pad dressing for the excessive drainage. Review of Resident #1's Nurse Progress Note, dated 05/29/24, indicated he/she complained of nausea and vomiting times three, weakness, and shortness of breath. Resident #1 was transferred to the Hospital Emergency Department on 5/29/24 for evaluation and was admitted for treatment. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she had been admitted for anemia in setting of an excessive anticoagulation dose, was found to have a spinal AV fistula, requiring blood transfusion and embolization (procedure used to block a blood vessel, used to stop bleeding). Review of Resident #1's Medication Error Report, dated 06/11/24, indicated that the Assistant Director of Nurses (ADON), neglected to note the recommendations from the Hospital Discharge Summary to decrease his/her Eliquis dose to 5 mg after the last 10 mg dose due to be given in the evening on 04/11/24. During an interview on 07/08/24 at 2:17 P.M., the Assistant Director of Nurses (ADON) said at the time of the incident she had been working as the evening nursing supervisor, that she recalled assisting with the admission process for Resident #1 and said she had completed his/her medication reconciliation form. The ADON said that she was unaware there was medication reconciliation error for Resident #1, until the DON informed her on 06/11/24. The ADON said Resident #1's Eliquis dose should have been changed to 5 mg by mouth twice a day (for a total of 10 mg a day) upon admission, but had not and that it was an error. The ADON said that once the auto-generated Alert Order Progress Note (for Resident #1's Eliquis order), had been generated by PCC, the physician should have been made aware and clarification of his/her Eliquis should have been completed at that time. During an interview on 07/08/24 at 12:46 P.M., the Charge Nurse said that once an Alert Order Progress Note from PCC appears in the resident's electronic medical record, the nurse is then responsible for informing the practitioner of the alert and obtaining a clarification order. During an interview on 07/08/24 at 1:19 P.M., Unit Manager #1 said she was unaware of the medication reconciliation error regarding Resident #1 until 06/11/24 when the former DON informed her. Unit Manager #1 said nurses should be reading the resident entire hospital discharge summary prior to reconciling the medications, that there are a lot of admissions, and some things get lost in translation. Unit Manager #1 said that either herself or the Charge Nurse should be reviewing all new admission and readmission medication reconciliation forms for accuracy. Unit Manager #1 said she had missed the change in Resident #1's Eliquis order and never saw the Alert Order Progress Note in PCC to address the Eliquis dose with a prescriber. During an interview on 07/08/24, the Interim Director of Nurses (DON) said that the former DON had made him aware of Resident #1's medication error in relation to medication administration sometime in June 2024. The Interim DON said that is the Facility's expectation for nurses to follow all policies and procedures for medication reconciliation, including having two licensed nurses sign the Medication Reconciliation Form to ensure accuracy and that the Management Staff double check all new admission as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to prevent a decline in range of motion causing the development of a contracture for one Resident (#78) out of a total sample of 33 residents. Findings include: Review of the facility policy titled Range of Motion and Mobility Guideline, dated September 25, 2019, indicated the following: *Residents will not experience an avoidable reduction in range of motion (ROM) *Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. *Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. *As part of the resident's comprehensive assessment, the nurse will identify the resident's: *Current range of motion of his or her joints *Limitations in movement or mobility *As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: *Contractures *The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. *The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. *The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Resident #78 was admitted to the facility in April 2023 with diagnoses including neuroleptic induced parkinsonism, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, muscle weakness and schizoaffective disorder. Review of Resident #78's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status score of 10 out of a possible 15 indicating that he/she has moderate cognitive impairment. Section GG of the MDS failed to indicate an impairment in range of motion of Resident #78's left hand/fingers. During an observation on 2/6/24 at 8:22 A.M., Resident #78 was observed sitting in his/her wheelchair eating breakfast. His/her left hand was closed into a half-closed fist with his/her fourth and fifth fingers bent at the first and second knuckles. Resident #78 was unable to straighten his/her fourth and fifth fingers. Resident #78 was observed holding a drink cup only using his/her thumb and index finger. During an interview on 2/7/24 at 10:32 A.M., Resident #78 said he/she can only move his/her thumb, first and second fingers on his/her left hand and could not move his/her fourth or fifth fingers. When observing the Resident's left palm, an indentation mark was observed where the fourth finger was pressing into the palm. Resident #78 said his/her left hand has been like this for about two months. During an interview on 2/8/24 at 7:51 A.M., Resident #78 said his/her left hand hurt and is painful. Review of Resident #78's physician's orders do not indicate an orthotic or any intervention for the Resident's left hand. Review of Resident #78's care plan dated 4/4/23 indicated the following: *Focus: The resident has limited physical mobility *Goal: The resident will remain free of complications related to immobility, including contractures. Resident #78's care plans did indicate a care plan for a contracture of his/her left hand. However, during an interview on 2/7/24 at 2:03 P.M., the Assistant Director of Rehab stated that the care plan inaccurately documented Resident #78's contracted hand as his/her left hand when it was meant for his/her right hand. During an interview on 2/7/24 at 11:10 A.M., Certified Nursing Assistant (CNA) #2 attempted to move the Resident #78's fingers on his/her left hand with the surveyor present. CNA #2 said she was unable to straighten the Resident's fourth and fifth fingers, saying the fingers were too tight. Resident #78 said it was painful when CNA #2 attempted to move his/her fingers. CNA #2 said she does a quick range of motion when she provides routine care for the residents. During an interview on 2/7/24 at 11:11 A.M., Nurse #3 observed Resident #78's left hand with the surveyor present. She said the Resident's left hand feels stiff and this was a new contracture. She continued to say that CNAs do not do range of motion and if they see something new they should tell a nurse. Nurse #3 said if a change in range of motion is observed by the nursing staff they would make a referral to the therapy department for an evaluation. Review of Resident #78's Occupational Therapy Evaluation and Plan of Treatment document, dated 12/12/23 indicated the following: *Musculoskeletal System Assessment: LUE (left upper extremity) = WFL (within functional limits) During an interview on 2/7/24 at 2:03 P.M., the Assistant Director of Rehab (ADOR) said long term care residents are screened by therapy during rounds every Monday. The ADOR said the therapy department receives referrals from nursing if a change in status is identified and if such referral was made a therapist would evaluate the resident. The ADOR said a change in range of motion would be a reason for a nursing referral. The ADOR continued to say if a staff member noticed a deficit, then therapy should have been notified so it can be treated. When asked about Resident #78, the ADOR said his/her left hand is within functional limits and if there was any deficit in range of motion then it would have been documented on the previous occupational therapy evaluation. The ADOR reviewed the evaluation and confirmed the Resident did not have a previous impairment in range of motion of his/her left hand. The ADOR continued to say that a contracture can form within 2 months, which is the time since Resident #78 was last seen by therapy. The ADOR said therapy has not received a referral for Resident #78's left hand and she would expect staff to document any deficit in range of motion in the medical record. During an interview on 2/7/24 at 2:27 P.M., the Occupational Therapist (OT) said she completed the occupational therapy evaluation on 12/12/23. The OT said the Resident has always kept his/her hand in a slight fist formation, but staff were always able to straighten all fingers on the left hand prior. The OT said she observed Resident #78's left hand and there is a possible new contracture since his/her last evaluation, and she would be completing a full evaluation to determine this. During an interview on 2/8/24 at 10:05 A.M., the Director of Nursing (DON) said CNAs should be doing range of motion during routine care and if staff observed a decline in range of motion it should be reported to the nurse or unit manager so therapy can be made aware. The DON continued to say that even though Nurse #3 said CNAs do not do range of motion during daily care, it is the expectation that they do. Review of Resident #78's Occupational Therapy Evaluation and Plan of Treatment dated 2/8/24 indicated the following: *Musculoskeletal System Assessment: LUE ROM (left upper extremity range of motion) = impaired. Ring finger = impaired, little finger = impaired. *Assessment Summary - Clinical Impressions: *Pt. (patient) referred to OT services due to nursing concerns for decreased functional use and concern for contracture of L (left) hand. Noted decreased use of 5th digit during self-feeding but able to extend when grasping cup. Approached after meal and pt presenting with L digits in flexed fisted position. When prompted to extend digits pt able to extend digits 2 and 3 WFL, digits 4 and 5 with decreased ROM at PIP (lower joint) and DIP (upper joint) as well as pt endorsing pain. Pt would benefit from OT services 2-3x/week to address bilateral contracture. During an interview on 2/8/24 at 1:04 P.M., the OT said she completed an evaluation of Resident #78's left hand and the Resident has a new contracture to the fifth finger, and he/she will be going back on therapy services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, policy reviews and interviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable mental, and psychosocial well-being for two Residents (#36 and #96) out of a total sample of 33 residents. Specifically, 1) the facility failed to provide non-pharmacological interventions or behavioral health services for Resident #36 as he/she had increasing behaviors and psychological distress leading to two involuntary hospitalizations for psychiatric concerns and 2) the facility failed to provide behavioral health services for Resident #96 after he/she displayed increased depressive symptoms. Findings include: Review of the facility policy titled, Behavior Assessment Guideline, dated June 2017, indicated the following: *The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. *Behavioral symptoms will be identified using facility approved behavioral screening tools and the comprehensive assessment. *Behavioral health services will be provided by qualified staff who have competencies and skills necessary to provide appropriate services to the residents. *Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. *The interdisciplinary team will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address and modifiable factors that may have contributed to the resident's change in condition, including: physical or medical changes; emotional, psychiatric, and or psychological stressors; and functional, social or environmental factors. *Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. *Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational environmental reasons for behavior. The care plan will include, as a minimum: in description of the behavioral symptoms and precipitating factors or situations. *Non-pharmacologic approaches will be utilized to the extent possible to avoid or reduce the use of antipsychotic medications to manage behavioral symptoms. 1. Resident #36 was admitted to the facility in December 2021 with diagnoses including major depression and dementia. Review of Resident #36's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated he/she had moderate cognitive impairment. Section E of the MDS indicated Resident #36 has had physically and verbally aggressive behaviors toward others for at least 1 out of 3 days assessed. During an interview on 2/9/24 at 8:51 A.M., Resident #36 said he/she has been feeling frustrated for a long time and is sad that he/she cannot leave the facility. Resident #36 said he/she would be willing to talk to someone about his/her problems if it would help. Review of Resident #36's medical record indicated that throughout his/her stay at the facility, he/she has been seen by a nurse practitioner for psychotropic medication management, however has never been seen by other behavioral services for counseling or non-pharmacological behavioral or emotional interventions. Resident #36 was sent out to the hospital with involuntary section 12 hospitalizations for psychiatric concerns on 9/20/23 and 10/3/23. Review of Resident #36's medical record indicated the following: Review of the clinical record indicated that between 8/20/23 and 8/23/23, Resident #36 showed increased behaviors such as being combative, verbally and physically abusive towards staff. On 8/24/23, Resident #36 was seen by the psychiatric nurse practitioner. The treatment encounter note indicated the Resident was seen for depression and failure to thrive and did not mention the Resident's increased behaviors or refusal of care. The note indicated 20 time was spent discussing patient's issues with staff, discussing patients issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing support and the recommendations were to continue medications as ordered. Review of the clinical record indicated that between 8/25/23 to 9/11/23, Resident #36 continued to display behaviors of irritability, aggression, verbal and physical abuse toward staff, and refusing care. The nursing note dated 9/3/23 indicated: Alert, verbal, to baseline. Refused to go bed on 3-11 shift in (his/her) wheelchair in-front of the nurses station. (He/she) was tried several times to be assisted to (his/her) bed but being verbally abusive with ' I will kill you' remark on the staff. After 2 AM (he/she) was falling asleep on (his/her) chair, & was physically wheeled to (his/her) room in order for to be changed & to go bed. (He/she) continues (his/her) verbal assault on the staff, was very soiled both (his/her) perineal in being red in which we can't put some barrier Creme this time secondary to (his/her) belligerent behavior. Went there several time for safety check, then about 3:30 AM found (him/her) sitting on (his/her) bedside with only (his/her) brief, offered to dressed but refused, also throw all (his/her) bedding onto the floor. This morning several attempt to give (his/her) med but continue to refused & verbally abusive, At one point ' you go home to china & you to Africa'. Safety maintained, no S/S of pain on assessment, continue plan of care. On 9/12/23, Resident #36 was seen by the psychiatric nurse practitioner, 9 days after he/she threatened to kill a staff member. The treatment encounter note indicated the Resident was irritable at times. The note indicated 20 time was spent discussing patient's issues with staff, discussing patients issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing support and the recommendations was to increase the Resident's antidepressant medication. Review of the clinical record indicated that between 9/13/23 to 9/20/23, Resident #36 continued to have aggressive behaviors toward staff, including sexual, physical and verbal abuse, refusing medications, and paranoia. Medication changes during this time frame were as follows: *On 9/12/23, Resident #36's Zoloft (antidepressant) was increased from 25 mg (milligrams) once a day to 50mg once a day. *On 9/15/23, Resident #36's Zoloft was decreased back down to 25mg. *On 9/14/23, Resident #36 was prescribed Seroquel (an antipsychotic) as follows: give 12.5 mg by mouth at bedtime. *On 9/16/23, Resident #36's Seroquel was changed to 12.5mg every 24 hours as needed. Review of the record from 8/20/23 until 9/20/23, did not indicate the social workers at the facility assessed or spent time with the resident during the August 2023 to September 2023 frame when he/she was demonstrating increased behaviors or prior to either hospitalization. The medical record also failed to indicate any social service notes after Resident #36's increased behaviors in August and September 2023 that showed social services involvement with monitoring or assisting with the Resident's behavior management and coordination of behavioral/psychiatric care services or providing the intervention as listed in his/her behavior care plan. Further, the medical record failed to indicate Resident #36 had ever been seen by a therapist for non-pharmacological interventions. Resident #36 was sent out on an involuntary basis on 9/20/23. Review of the discharge paperwork from the hospital dated 9/26/23 indicated (The Resident) was increasingly combative with staff at the nursing home, yelling, cursing, physically aggressive, and reports HI (homicidal ideation), SI (suicidal ideation). Refusing medications. (he/she) was sent to the ED on sec 12 (involuntary hospitalization) due to inability to manage (his/her) behaviors. In ED (he/she) was agitated and aggressive, not allowing care, exam, or labs. The hospital discharged the Resident back to this facility as stable. Review of Resident #36's care plans failed to indicate a care plan for Resident #36's SI/HI had been developed upon return from the hospital. Review of the nursing notes after readmission to the facility indicated the following: *9/28/23: Resident was resistive and combative tonight refusing to go to bed. Stayed by the elevator trying to put a code in. Supervisor came up to help and convinced (him/her) to get ADL (self care) care and go to bed. Asleep at this time. *9/28/23: Continue to be non cooperative with care, aggressive when trying to help with ADLs. Patient verbally abusive to staff. Refused all meds, attempted multiple times. RNP (Registered Nurse Practitioner) covering for Dr made aware of patient behavior, episodes of delusion. Family was contacted by NP (Nurse Practitioner) and came to visit. Seroquel 50mg given Per HCP agreement and per NP order. 15 min safety check initiated, monitored closely during the shift. Review of the nurse practitioner note dated 9/28/23 indicated the following: Today, pt is delusional, thinking my pen is a knife. When auscultating (his/her) heart I briefly touched (his/her) necklace which (he/she) informed me was voo doo and made a cutthroat gesture. (He/she) is holding on to a metal fork, refusing to let it go and threatening staff. The psychiatric nurse practitioner saw the Resident on 9/29/23 and the encounter note indicated the following: Pt has had severe psychotic break. He/she mistook a pen as a knife. (He/she) is at risk to him/herself and others. Staff placed (him/her) on 15 minute checks. Mood: depressed, psychotic, anxiety. Severity: severe. 20 time was spent discussing patient's issues with staff, discussing patient's issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing emotional or behavioral support. After this visit, Resident #36's Zoloft dose was increased from 25mg once daily to 25mg twice daily. The psychiatric nurse practitioner saw the Resident again on 10/2/23 and the encounter note indicated the following: Send to acute psych. (His/her) condition has worsened and not improved by Zyprexa. Review of the clinical record indicated that Resident #36 was not sent out to the hospital on [DATE] and continued to have aggressive behaviors, including physical and verbal abuse. On 10/3/23, a nursing progress note indicated the following: 10/3/23: Situation: patient exhibiting aggressive behavior towards staff, verbally abusive, threatening (sic) nurse I will kill you anyway b ., I will strangle you My son is coming with his gun to kill you. Patient has been non cooperative with with meds, food, ADL care since yesterday. (He/she) is at risk for (him/herself) and other. 15 minutes safety check was initiated since last week due to safety concern and exit seeking. Assessment/Appearance: Verbally and physical aggressive to staff and at time to other residents, very delusional. Refused to eat or drink properly, appears weaker. Recommendations: (His/her) behavioral disturbance, increased agitation, cannot be managed at the nursing home, sent to your facility for further evaluation and care. Resident #36 was sent out on an involuntary basis on 10/3/23, 5 days after the psychiatric nurse practitioner documented that Resident #36 was experiencing a severe psychotic break and he/she was unsafe to self and others. Resident #36 was re-admitted to the facility on [DATE]. Upon readmission the facility did not develop a care plan for SI/HI and no new interventions were added to his/her behavioral care plans. Review of the Resident's care plan also failed to indicate a care plan was in place for the use of psychotropic/antipsychotic medications. The psychiatric nurse practitioner saw the Resident on 10/24/23; two weeks after his/her readmission for a psychiatric hospitalization, and the encounter note indicated the following: Staff report (he/she) has periods of irritability. Delusions or hallucinations: has reported hallucinations of pen looking like a knife. Suicidal or homicidal: (his/her) thought process is nonsensical. 30 time was spent discussing patient's issues with staff, discussing patient's issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing emotional or behavioral support. The psychiatric nurse practitioner saw Resident #36 on 11/14/23 and the encounter note indicated the following: Delusions or hallucinations: has reported hallucinations of pen looking like a knife. Suicidal or homicidal: (his/her) thought process is nonsensical. 30 time was spent discussing patient's issues with staff, discussing patient's issues, reviewing chart and labs, patient in staff education, coordinating patients care in regards to psychiatric diagnosis. The note failed to indicate the nurse practitioner spent time with the resident providing emotional or behavioral support. Final review of Resident #36's medical record indicated the following: *Social service notes dated 10/13/23 and 10/20/23 that indicated Resident #36 would be followed by psychiatric services closely. *A physician note dated 10/12/23 that indicated the medical team would like the Resident to be continued to be seen by psychiatric services. *A nurse practitioner note dated 1/16/24 that indicated the medical team would like the Resident to be continued to be seen by psychiatric services. *Behavior sheets from October 2023 to February 2024 indicated the Resident continued to have behaviors of being sexually inappropriate, abusive language, yelling/screaming, pinching/scratching/spitting, refusal of care and wandering. *The Resident has not been by any psychiatric nurse practitioner or behavioral health counselor since November 2023. The psychiatric nurse practitioner no longer works at the facility and was not able to be interviewed. During an interview on 2/08/24 at 12:54 P.M., Nurse #3 said Resident #36 wants to return to his/her home and leaving the facility is a trigger for his/her increased behaviors. Nurse #3 said she noticed a change in the Resident's behaviors started when his/her family took him/her off the unit and he/she did not want to return to the unit. Nurse #3 said when the Resident was triggered and became more agitated and aggressive, the staff would just leave him/her alone. Nurse #3 said she never had a conversation with the social worker on providing Resident #36 with any services beyond the psychiatric nurse practitioner. During an interview on 2/8/24 at 11:13 A.M., Social Worker (SW) #1 said she is a full time social worker in the facility, however does not work on the floor Resident #36 resides on. SW #1 said the responsibility of the social workers in the facility is to jump in to situations that are concerning for residents, including increased behaviors or change in mood, and try to refer these residents to behavioral services. SW #1 said the facility has the use of a psychiatric nurse practitioner but has never had behavioral health services for counseling/talk therapy and said there are definitely residents in the facility who would benefit from that type of service. SW#1 said she talks to residents, but it is not a counseling session. SW #1 said that when behavioral services in not available, social services and the nursing department fill that need. SW #1 said some interventions available when behavioral services are not available would be talking to the resident, distracting/redirecting the resident, and addressing any concerns the resident may have. SW#1 said SW#2 would have been responsible for intervening with Resident #36's care and she is not aware if Resident #36 is currently receiving behavioral health services. SW #1 said the facility recently made a change with behavioral health service providers and the facility was without a provider for about a month. During an interview on 2/9/24 at 9:49 A.M., SW #2 said she has been supporting the building on and off for the last couple of years and she is the main social worker for the floor Resident #36 resides on. SW #2 says she works 16 hours a week and all her work is completed remotely. SW #2 said she primarily assists the building with MDS interviews and care plan meetings and however else she can help. SW #2 said she would meet with residents as needed if brought to her attention but does not recall any staff telling her about a specific resident concern. SW #2 said she does not remember being involved with Resident #36 in the months of August and September 2023 and was unable to recall specifics about Resident #36's care during the interview. SW #2 said there was a change in psychiatric providers in the facility and the facility she expected the facility to ensure all residents who were being treated prior would also be seen by the new provider. SW #2 was unaware if Resident #36 has continued to be seen by psychiatric services. On 2/9/24 at 8:18 A.M., SW #3 and SW#1 were interviewed. SW #3 said she is a social service assistant and is responsible for scheduling appointments for residents on the unit Resident #36 resides. SW #3 said she was unsure if Resident #36 has continued to be seen for psychiatric services since November of 2023. SW #1 said she didn't believe any behavioral health services, such as talk therapy, would have been beneficial to Resident #36, however, when asked if the facility had ever attempted this, she said they had not. SW #1 said she would expect any individual with increased behaviors or threats of harm would be continually seen by the psychiatric nurse practitioner. SW #1 was unaware if Resident #36 was still being followed by the psychiatric nurse practitioner. During an interview on 2/9/24 at 10:10 A.M., the Administrator and Director of Nursing (DON) said the facility has had a psychiatric nurse practitioner in the building, however there was a lapse in coverage from mid November 2023 to January 2024 when the facility changed providers. The Administrator said the facility has never had a counselor available to the residents of the facility and both the Administrator and DON said they felt there were residents in the facility who would benefit from that service. The DON said that when the behavioral service providers changed, she went through all residents to ensure anyone that was on services prior would have services with the new provider. Both the Administrator and Director of Nursing said there were weekly at risk meetings to discuss residents' behaviors and Resident #36 was discussed in an attempt to provide non-pharmacological behavioral interventions. Review of the risk meeting notes from August 2023 to February 2024 noted the Resident's increased behaviors, however failed to indicate any new behavioral interventions were discussed. During an interview on 2/9/23 at approximately 11:00 A.M., the Administrator confirmed Resident #36 has not been seen by any psychiatric services since November of 2023.2. Resident #96 was admitted to the facility in April 2023 with diagnoses including end stage renal disease and cognitive communication disorder, delusional disorder, adjustment disorder, and major depressive disorder. Review of Resident #96's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she is severely cognitively impaired and requires assistance with bathing, dressing and transfers. Additional Review of the MDS indicated he/she triggered for moderate depression on section D: Mood Interview; which indicated that he/she felt down/depressed or hopeless, feeling tired or little energy and changes in appetite nearly every day over the previous 14 days. During an interview on 2/9/24 at 8:51 A.M., Resident #96 presented with flat affect and depressed mood. Resident #96 said my family comes and visits and we laugh, they leave and I get depressed. Resident #96 said he/she did not believe he/she had been offered counseling services. Review of Resident #96's care plans, indicated: Focus: Resident at risk for potential decline in mood state related to dx (diagnosis) of mood disorder, major depressive disorder, 4/3/23 Interventions: Allow resident the opportunity to express feelings, needs, and concerns to staff provide reassurance as needed. Attempt to determine potential triggers of alteration in mood and adjust as able. Encourage active participation in and out of room, therapeutic and leisure programs of choice. Refer to alternate support systems as appropriate. Focus: Psychotropic [medications], 4/1/23 Interventions: Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness. Referral to psych services. Review of Resident #96's clinical progress notes indicated the following: Behavioral Health Nurse Practitioner 11/21/23: Pt (patient) seen for depression and anxiety. he/she is receiving Staff MD reporting today that pt refused dialysis (harm to self) and has higher level of persistent self absorption, anger, paranoia. Pt was strongly preoccupied about his/her family and why they are not coming to his/her aid. More depressed today, no si/hi (suicidal ideation and homicidal ideation). Patient was seen in today in his/her room space. He/she was strongly perseverating about his/her family. With his/her recent disabling medical issues, he/she is upset they are not helping him/her more. he/she is presenting with anxiety to staff. Nurse Practitioner note 12/26/23: Seen in his/her room. He/she appears disheveled in bed. He/she complains of body ache and pains, malaise and fatigue. His/her words shabby. With respect to his/her mood, he/she states, I am afraid of going to the ED (emergency department) [because] I cant control myself. I yell at people. He/she recently decided to stop Prozac, (an antidepressant medication) and abilify (an anti-psychotic medication). Monitor mood closely. Social Services note 12/30/23: This writer met with resident on this date to complete BIMS and PHQ 9. He/she repeated the 3 words then refused the rest of the evaluation stating this is the year for dying and I'm gonna die. Asked for clarification and asked if he/she was having thoughts, plans means to harm himself/herself and to kill himself/herself which he/she denied. Resident stated he/she was very angry and that he/she was sick. Attempted again to finish evaluations and he/she closed his/her eyes. Nursing outside of door notified and both nurse and aid stated this is Resident behavior since his/her return from hospital (11/29/23), and that he/she had been on psych meds and refused them. Discussed referral for psych services and nurse stated he/she would put in for consult. Nurse progress note 12/30/23: Pt very agitated this morning. Stated, I'm going to die, but I'm not ready. Pt did not finish his/her evaluation. Social Services note 1/2/24: Social Worker and Social Service Assistant attempted to check in multiple times with Resident. Daughter had been visiting and asked for SS (social service) team to come back at a later time. Nurse practitioner note 1/4/24: Current moderate episode of major depression disorder. Per my discussion with daughter, he/she had no h/o (history of) depression for many years, no [in patient] psych admission. While in rehab, has expressed some sadness over current health situation and loss of functional independence. Used to be on Prozac and abilify but [patient] wanted them stopped. He/she has expressed statements about not wanting to die to staff. He/she denies SI/HI (suicidal and homicidal ideation) Contracted for safety today. He/she will consider restarting on Prozac. Appreciate psych input. Physician progress note 1/11/24: Resident told me he's/she's sad about the state of his/her health, doesn't want to die and has no plans of hurting himself/herself or other people. Current moderate episode of major depressive disorder. H/O depression for many years, sadness over loss of function and state of health. Today, wiling to restart fluoxetine (Prozac). Appreciate psych input. Nurse Progress note 1/24/24: Resident alert and oriented with baseline screaming, yelling, calling nursing names nonstop during the shift. Pain med was offered x 3, refused all three times stated his/her daughter told him/her not to take pain pill from us. The clinical record failed to indicate Resident #96 had been seen by behavioral health services since 11/21/23 despite a documented increase in depressive symptoms. During an interview on 2/9/24 at 8:54 A.M., Unit Manager #1 said that Resident #96 has become more depressed and sad about his/her current health status. Unit Manager #1 said that the facility has a psychiatrist that comes in, but does not currently have any providers for therapy services. During an interview on 2/9/24 at 9:35 A.M., Social Worker #1 said that Resident #96's mood has been variable and with his/her decline in health, has had some depression. Social Worker #1 said that Resident #96 would benefit from counseling services. During an interview on 2/9/24 at 10:10 A.M., the Administrator and Director of Nursing (DON) said that there had been a change in behavioral health services for the facility and the new service provider had just started. The Administrator said that the new behavioral health services is able to offer counseling services. The Administrator and DON said that in the event that a resident was in need of supportive counseling, outside vendors could be contacted. The Administrator and DON were not aware that Resident #96 had not been seen by behavioral health services since 11/21/24. During a follow up interview on 2/9/24 at 11:39 A.M., the Administrator confirmed Resident #96 had not been seen by behavioral health services since 11/21/24.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the administration of an anticonvulsant for management and treatment of seizures, the facility failed to ensure services provided by nursing met professional standards of practice, when upon admission to the facility the Hospital Discharge Summary and medication list were not thoroughly reviewed by nursing and his/her medications were not accurately reconciled. Upon admission, the need for Resident #1 to be continued on an anticonvulsant medication was not communicated to the physician, and therefore not ordered or administered. As a result, Resident #1 went nine days without being administered his/her anticonvulsant medication, he/she experienced seizure activity, and required emergent transfer to the Hospital Emergency Department for evaluation and treatment. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the facility in January 2023, diagnoses included confusion, end stage renal failure requiring hemodialysis (a machine that filters your blood), dislodged dialysis catheter, bipolar disease, hypertension and a history of repeated falls. Review of the Hospital Discharge Summary, Medication Administration Record, Transfer Report, dated 1/12/23, indicated that Resident #1's Active Medication Orders included that he/she was being administered Lacosamide (Vimpat, anticonvulsant used to treat seizures) 100 milligrams (mg) by mouth two times a day, (for seizures). Further review of the Discharge Summary indicated Resident #1 was to continue to be administered Lacosamide at his/her facility. However, review of Resident #1's Physician Orders, dated January 2023, indicated there were no physician orders for the medication Lacosamide for treatment of his/her seizures. Review of Resident #1's Medication Administration Record, dated January 2023, also indicated there were no physician orders related to the administration of Lacosamide. Review of WebMD, Uses, Side Effects, and More related to Vimpat (Lacosamide an anticonvulsant or antiepileptic drug), indicated it is used to prevent and control seizures. It works by reducing the spread of seizure activity in the brain. This medication works best when the amount of drug in the body is kept at a constant level. Patients should not stop taking this medication without first consulting with their physician. Seizures can become worse when the drug is suddenly stopped. Review of Resident #1's Nursing Progress Note, dated 1/23/23, indicated that Resident #1 required hospitalization following possible seizure activity at 6:45 A.M. Review of Resident #1's medical record indicated there was no documentation to support that an admission chart audit (checklist) had been completed by nursing. Per the Facility, an admission chart audit includes nursing review of the referring facility discharge summary and medication reconciliation. During interview on 2/07/23 at 2:19 P.M., the Second Floor Unit Manager said the weekend Nursing Supervisor on duty would have completed the admission chart audit for Resident #1. The Unit Manager said a checklist is used for the audits and when completed, the audit checklist is filed in the front of the residents chart. The Unit Manager said she had not noticed that Resident #1's admission chart audit had not been completed. During interview on 2/07/23 at 3:20 P.M., the admission Nurse said that she was not working when Resident #1 was admitted , but said when she came to work on Monday 1/16/23, she reviewed the records for the new admissions that had come in over the previous few days to check for the completion of admission chart audits. The admission Nurse said she did not recall seeing a chart audit completed for Resident #1. During interview on 2/07/23 at 3:45 P.M., the Minimum Data Set (MDS) Nurse said that she reviews all the hospital paperwork for each new admission. The MDS Nurse said she completed a medication review but, can only use medications that have been administered in the facility. The MDS Nurse said when something is out of the ordinary, the nursing staff is notified. The MDS Nurse said she did not recall seeing the medication Lacosamide in Resident #1's discharge summary. During interview on 2/7/23 at 10:35 A.M., the Assistant Director of Nursing (ADON) said the facility admission process is to complete a post admission chart audit that begins as soon as the admission is complete. The ADON said a facility audit tool (checklist) is utilized for all admissions. The ADON said the Nursing Supervisors, the admission Nurse, and the Unit Managers all participate in completing admission audits. The ADON said, although Resident #1 was being administered seizure medication while in the Hospital, when nursing first reviewed the Hospital Discharge medication list, they did not see any orders for seizure medication. The ADON said the order for the seizure medication was discovered deeper in Resident #1's Hospital Discharge Summary, after he/she required hospitalization for seizure activity, and they reviewed his/her Discharge Summary again. The facility was unable to provide the surveyor with Resident #1's admission chart audit tool, or any other documentation to support a chart audit had been completed by nursing.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who required the administration of anticonvulsant medication for the treatment of seizures, the facility failed to ensure his/her medications were accurately reconciled by nursing, in an effort to ensure he/she was free from a significant medication error. As a result of a medication reconciliation error, Resident #1 went nine days without being administered his/her anticonvulsant mediation, and required emergent transfer to the Hospital Emergency Department due to the onset of seizure activity. Findings include: The Facility Policy titled Reconciliation of Medications on admission Guideline, dated as revised 1/26/23, indicated the medication reconciliation form, the discharge summary from the referring facility, the most recent medication administration record, and a medication history from the resident/family were to be used to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission for accurate communication to the attending physician. The Policy further indicated that medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking will continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. Use an approved medication reconciliation form to list all medications from the medical history, the discharge summary and the medication administration record and the admitting orders. Resident #1 was admitted to the facility in January 2023, with diagnoses that included confusion, end stage renal failure requiring hemodialysis (a machine that filters your blood), dislodged dialysis catheter, bipolar disorder, hypertension, and a history of repeated falls. Review of the Hospital Discharge Summary, Medication Administration Record, Transfer Report, dated 1/12/23, indicated that Resident #1's Active Medication Orders included that he/she was being administered Lacosamide (Vimpat, anticonvulsant used to treat seizures) 100 milligrams (mg) by mouth two times a day, (for seizures). Further review of the Discharge Summary indicated Resident #1 was to continue to be administered Lacosamide at his/her facility. However, review of the current Physician Orders, dated January 2023, indicated there were no physician orders for the medication Lacosamide for seizures. Review of Resident #1's Medication Administration Record (MAR), dated January 2023, indicated there was no physician orders related to the administration of Lacosamide. Further review of Resident #1's medical record and documentation related to his/her admission indicated there was no documentation to support that a medication reconciliation was performed by nursing, and the facility was unable to provide the surveyor with a copy of Resident #1's medication reconciliation form that should have been completed by nursing upon admission. Furthermore the omission of Resident #1's Lacosomide was not identified by the facility until nine days after Resident #1's admission, when he/she required transfer and re-admission to the Hospital, after experiencing seizure activity. Review of WebMD, Uses, Side Effects, and More related to Vimpat (Lacosamide an anticonvulsant or antiepileptic drug), indicated it is used to prevent and control seizures. It works by reducing the spread of seizure activity in the brain. This medication works best when the amount of drug in the body is kept at a constant level. Patients should not stop taking this medication without first consulting with their physician. Seizures can become worse when the drug is suddenly stopped. Review of Resident #1's Nursing Progress Note, dated 1/23/23, indicated that Resident #1 required hospitalization following possible seizure activity at 6:45 A.M. During interview on 2/7/23 at 2:19 P.M., the Second Floor Unit Manager said that nurses should reconcile all admission medications from the Hospital Discharge Summary medication list. The Unit Manager said nurses must look through all the documentation that comes with the resident. The Unit Manager said when the documentation differs when she is completing an admission or an audit, she would check with the resident and or family for clarification. During interview on 3/02/23 at 4:10 P.M., the Nursing Supervisor said he worked the second shift and primarily assisted with the 3:00 P.M.-11:00 P.M. admissions, reviewed the medications and the medication lists. The Nursing Supervisor said he would then call the attending physician and they would review the medications together, and the physician would confirm the medication orders. The Nursing Supervisor said he would then enter the medications into the computer and the nurse on duty would complete the resident admission assessment. The Nursing Supervisor said the Hospital Discharge Summary, upon the resident's admission must be read word by word and any concerns should be brought to the physician's attention. The Nursing Supervisor said he can only assume the physician reviews the entire record and the Hospital Discharge Summary, but he does not witness that process. The Nursing Supervisor said he did not recall any incident with Resident #1 and was not aware of the need to use a medication reconciliation form for admissions at that time. The Nursing Supervisor then said he no longer works at the facility. During interview on 2/07/23 at 10:35 A.M., the ADON said, although Resident #1 was being administered seizure medication while in the Hospital, when nursing first reviewed the Hospital Discharge medication list, they did not see any orders for seizure medication. The ADON said the order for the seizure medication was discovered deeper in Resident #1's Hospital Discharge Summary, after he/she required hospitalization for seizure activity, and they reviewed his/her Discharge Summary again.