**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R28 Review of R28's face sheet dated 1/17/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: dysphasia following cerebral infarction (swallowing problems after a stroke), diabetes mellitus 2, bipolar disorder, cognitive communication deficit, and muscle weakness. He was not his own responsible party. Record review for R28 revealed the monthly pharmacy reviews for March, June and November 2024 were missing. During an interview with the Director of Nursing (DON) on 1/17/25 at 9:08 AM, she confirmed that the reviews for R28 for March, June and November 2024 were missing. R46 Review of R46's face sheet dated 1/17/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included dementia, cognitive communication deficit, and post traumatic stress disorder. She was not her own responsible party. Record review for R46 revealed that the pharmacy reviews were missing for February, June and November 2024. During an interview with the Director of Nursing (DON) on 1/17/25 at 9:08 AM, she confirmed that the reviews for R46 for February, June and November 2024 were missing. R66 Review of R66's face sheet dated 1/17/25 revealed he was [AGE] year-old male admitted to the facility on [DATE] and had diagnoses that included: Parkinson's disease, tremor, adjustment disorder, and dementia. He was not his own responsible party. Record Review for R66 revealed the pharmacy reviews for March, June and October 2024 were missing. During an interview with the Director of Nursing (DON) on 1/17/25 at 9:08 AM, she confirmed that the reviews for R66 for March, June and October 2024 were missing. The DON said the facility was not aware the Pharmacist had not completed all the monthly reviews in 2024 until 1/16/25 when the survey team requested pharmacy reviews. Based on interview and record review, the facility failed to ensure that monthly pharmacy reviews were conducted for 5 of 5 residents (R3, R16, R28, R46, & R66) reviewed for monthly pharmacy medication regimen reviews, resulting in residents medications not being reviewed and the potential for an adverse outcome from medications and/or lack of assessment and monitoring of medications. Findings include: A review of the facility's Drug/Medication Regiment Review for All Residents policy, last revised 8/22, revealed the Medication Regimen Review (MRR) is a thorough evaluation of the medication regiment of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) and potential risks associated with medication. The policy further revealed the medication regimen of each resident must be reviewed by a licensed pharmacist at least once a month. R3 A review of R3's admission Record, dated 1/17/25, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's admission Record revealed multiple diagnoses that included severe dementia with psychotic disturbance, late onset Alzheimer's Disease, visual hallucinations, and atrial fibrillation (an irregular rapid heart rate that commonly causes poor blood flow). A review of R3's medical records (electronic and paper), dated 11/16/23 to 1/16/25, failed to reveal monthly pharmacy medication regimen reviews for December 2023, March 2024, June 2024, October 2024, and November 2024. During an interview on 01/16/25 at 02:50 PM, the Director of Nursing (DON) stated they have not had a change in pharmacy or issues with their pharmacy. She stated she did not know why R3's pharmacy reviews were missing and/or not conducted for December 2023, March 2024, June 2024, October 2024, and November 2024. She stated she would see if she can locate the documentation. The surveyor requested copies of any documentation that the DON can locate, if available. The DON verbalized understanding and stated she would get the documentation to the surveyor as soon as possible, if she can locate anything. During an interview on 01/16/25 at 03:35 PM, the DON stated she could not find any of R3's missing pharmacy reviews. She stated she also called the pharmacy and they do not have them. The DON it appears that the pharmacist did not conduct a monthly medication regiment review for R3 during the months of December 2023, March 2024, June 2024, October 2024, and November 2024. The DON further stated they have changed pharmacists and the new one is more organized. R16 A review of R16's admission Record, dated 1/16/25, revealed R16 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R16's admission Record revealed multiple diagnoses that included diabetes mellitus type 2, seizures, depression, and anxiety. A review of R16 medical records (electronic and paper), dated 2/1/24 to 1/16/25, failed to reveal monthly pharmacy medication regimen reviews for March 2024, June 2024, October 2024, and November 2024. During an interview on 01/16/25 at 02:50 PM, the DON stated they have not had a change in pharmacy or issues with their pharmacy. She stated she did not know why R16's pharmacy reviews were missing and/or not conducted for March 2024, June 2024, October 2024, and November 2024. She stated she would see if she can locate the documentation. The surveyor requested copies of any documentation that the DON can locate, if available. The DON verbalized understanding and stated she would get the documentation to the surveyor as soon as possible, if she can locate anything. During an interview on 01/16/25 at 03:35 PM, the DON stated she could not find any of R16's missing pharmacy reviews. She stated she also called the pharmacy and they do not have them. The DON it appears that the pharmacist did not conducted monthly medication regiment review for R16 during the months of March 2024, June 2024, October 2024, and November 2024. The DON further stated they have changed pharmacists and the new one is more organized.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policies and procedures and provide documentation justifying psychotropic medication for 1 (Resident #2), out of 5 residents reviewed for psychotropic medications, resulting in the potential for unnecessary medication orders/administration. Findings include: Review of a policy titled Use of Psychotropic Medication last revised on 5/22 revealed: PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Resident #2 (R2) Review of a Face Sheet revealed R2 admitted to the facility on [DATE] and is on hospice and has a diagnosis of dementia. Review of a physician order with a start date of 9/1/23 for R2 revealed Ativan 0.5 mg (milligrams) tablet every 6 hours as needed for anxiety and dyspnea was ordered with no stop date. Review of Medical Records for R2 revealed there was no thorough documentation about medical justification by the prescribing practitioner for the ongoing use of PRN (as needed) Ativan that was ordered with no stop date. In an interview on 11/15/23 at 3:21 PM, Unit Manager I reported she is aware of the need for the practitioner to provide documentation for PRN Ativan that is ordered for longer than 14 days and was not able to find documentation in R2s chart to justify the continued order. In an interview on 11/16/23 at 10:00 AM, the Director of Nursing (DON) reported the PRN Ativan order fell through the cracks and acknowledged the appropriate documentation from the physician was missing from the medical record.

Based on observation, interview, and record review, the facility failed to store medications in safe temperature ranges for 1 medication refrigerator (1st floor) of 3 medication refrigerators reviewed, resulting in the potential for medications to become ineffective. Findings included: During a review of medications being stored in the first floor medication refrigerator on 11/15/23 at 8:31 AM, the refrigerator temperature log was reviewed with Registered Nurse (RN) A. The temperature log revealed, If the temperature deviates from 36 degrees to 46 degrees notify Infection Control and Maintenance. Temperatures were recorded once a day from January 1, 2023, to November 15, 2023. Temperatures ranged from 34 degrees to 42 degrees. The sheet recorded 16 times where the refrigerator was 34 degrees and on 5 dates there was no recorded temperature. RN A said she was not aware of the low temperatures or if anyone had been notified of the low temperatures. RN A said she was aware that the refrigerator did freeze over at times and maintenance did defrost the refrigerator. Insulin (diabetic medication), Trulicity (blood sugar regulation medication) and suppositories (medication for bowel care) where stored in the refrigerator at the time of the observation. During an interview with the Nursing Home Administrator (NHA) and Pharmacist B on the telephone on 11/15/23 at 10:15 AM the first floor medication refrigerator log was reviewed. Pharmacist B confirmed the safe storage range for all medications was 36 to 46 degrees Fahrenheit. He also confirmed it was a concern if the refrigerator was getting down to 34 degree and was having issues with intermittent freezing requiring defrosting. During an interview with the Director of Nursing (DON) on 11/16/23 at 8:53 AM, she reported she was not aware of the first floor medication temperatures dropping below the recommended temperature until yesterday. She said the maintenance staff reported they defrosted that refrigerator last July and yesterday they turned the dial down one setting and placed 2 thermometers in the refrigerator. Maintenance staff checked that refrigerator this morning at it was 38 degrees. Review of the facility provided information labeled, Food and Drug Administration regarding Insulin Storage and Switching Between Products in an Emergency revealed. According to the product labels from all three U.S. insulin manufactures, it is recommended that insulin be stored in a refrigerator at approximately 36 degrees F (Fahrenheit) to 46 degrees F. Unopened and stored in this manner, these products maintain potency until the expiration date on the package. Do not use insulin that has been frozen.