**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that physician's orders were followed for 1 of 2 residents reviewed for choices in a final sample of 12 residents. (Resident identifier is #4.) Findings include: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Review on 4/8/25 of Resident #4's nursing note dated 4/3/25 revealed Per [provider name omitted], beginning GDR [Gradual Dose Reduction] of Lyrica. See MAR for GDR schedule. As [pronoun omitted] now is on 200 mg [milligrams] TID [three times a day], the taper will reduce [pronoun omitted] by 100 mg per day, to be completed in 25 days. Review on 4/8/25 of Resident #4's nursing note dated 4/7/25 revealed Upon attempting to give the noon dose of Lyrica (100 mg ordered), nurse realized we did not have any 100 mg capsules in-house. Further investigation revealed [Resident #4's name omitted] has been continually receiving [pronoun omitted] previous dose of 200 mg TID instead of starting the GDR [100 mg dose] as scheduled on 4/4/25 . Review on 4/9/25 of Resident #4's April 2025's MAR revealed an order for Lyrica (Pregabalin) Oral Capsule 100 mg by mouth one time a day for 5 days with a start date of 4/4/25 and scheduled for noon time. Further review revealed that the MAR indicated that the Lyrica 100 mg was administered from 4/4/25 through 4/6/25. Review on 4/8/25 of Resident #4's narcotic administration record revealed that Lyrica 200 mg was administered on 4/4/25 at 12:40 p.m., 4/5/25 at 1:00 p.m., and 4/6/25 at 11:08 a.m. There was no documentation of Lyrica 100 mg being administered on 4/4/25 through 4/6/25. Interview on 4/9/25 at approximately 12:00 p.m. with Staff C (Registered Nurse) confirmed that Resident #4 received the wrong dose of Lyrica, which was scheduled for noon, from 4/4/25 through 4/6/25.

Based on record review, policy review, and interview, it was determined that the facility failed to document that the resident and/or the resident's representative was fully informed of the risk and benefits of psychotropic medications for 5 of 5 residents reviewed for unnecessary medications in a final sample of 12 residents. (Resident identifiers are #23, #13, #28, #29, and #27.) Findings include: Resident #23 Review on 4/9/25 of Resident #23's current physician's orders revealed the following orders: Citalopram Hydrobromide Tablet 10 mg. (milligrams), Give 1 tablet by mouth one time a day related to depression, unspecified, order dated 4/11/23, Lorazepam Tablet 0.5 mg. Give 0.5 mg. by mouth every 4 hours as needed for anxiety/EOL (end of life), for 12 months, dated 3/28/25. Review 4/9/25 of Resident #23's medical record revealed no documentation that the resident and/or the resident's representative had been informed of the risks and benefits of the above medications. Resident #13 Review on 4/9/25 of Resident #13's current physician's orders revealed the following orders: Lexapro 5mg PO (by mouth) QD (Daily) (Anxiety), dated 4/19/24. Lorazepam Tablet 0.5 mg. Give 1 tablet by mouth every 4 hours as needed for anxiety for 12 months, and give 1 tablet by mouth three times a day related to anxiety disorder, dated 12/12/24. Review 4/9/25 of Resident #13's medical record revealed no documentation that the resident and/or the resident's representative had been informed of the risks and benefits of the above medications. Resident #29 Review on 4/9/25 of Resident #29's current physician's orders revealed the following orders: Mirtazapine Tablet 15 mg (milligrams), Give 1 tablet by mouth at bedtime related to insomnia, unspecified, order dated 4/2/2025. Sertraline HCl Oral Tablet (Sertraline HCl) Give 25 mg by mouth one time a day related to generalized anxiety disorder, order dated 4/2/25. Sertraline HCl Oral Tablet (Sertraline HCl) Give 50 mg by mouth one time a day related to generalized anxiety disorder, order dated 4/2/25. Review 4/9/25 of Resident #29's medical record revealed no documentation that the resident and/or the resident's representative had been informed of the risks and benefits of the above medications. Resident #28 Review on 4/9/25 of Resident #28's current physician's orders revealed the following orders: Sertraline HCl Oral Capsule 200 mg (Sertraline HCl) GIve 1 capsule orally one time a day related to major depressive disorder, recurrent, unspecified, order dated 12/5/24. Review 4/9/25 of Resident #28's medical record revealed no documentation that the resident and/or the resident's representative had been informed of the risks and benefits of the above medications. Resident #27 Review on 4/9/25 of Resident #27's current physician's orders revealed the following order: Citalopram Hydrobromide Oral Tablet (Citalopram Hydrobromide) Give 20 mg by mouth one time a day related to depression, unspecified, order dated 1/16/25. Review 4/9/25 of Resident #27's medical record revealed no documentation that the resident and/or the resident's representative had been informed of the risks and benefits of the above medications. Interview on 4/9/25 at approximately 2:00 p.m. with Staff D (Registered Nurse) confirmed there was no documentation that the above residents and/or the resident's representatives were fully informed of the risk and benefits of psychotropic medications prior to starting treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow professional standards by moving a resident who had fallen for 1 of 2 residents reviewed for closed records in a final sample of 14 residents (Resident identifier #142). Findings Include: Review on 3/17/23 at 12:45 p.m. of Resident #142's progress note, dated 2/25/23 at 07:11 a.m. and signed by Staff A (Registered Nurse), revealed that [pronoun omitted] was alerted at 06:10 a.m. by a LNA [Licensed Nursing Assistant] that resident had fallen and was on the floor in [pronoun omitted] room. [Pronoun omitted] is found sitting with back to wall across from the bathroom door. Legs were outstretched and left leg externally rotated. [Pronoun omitted] screams out in pain when writer attempted to touch the leg. Vital signs . Staff A directed two LNAs to assist with Hoyer [a mechanical lift] and get Resident #142 off the floor and into bed. Notifications to family and MD [Medical Doctor] with orders to send to ED [Emergency Department]. Interview on 3/17/23 at 1:30 p.m. with Staff C (LNA) revealed that he/she as instructed by Staff C transferred Resident #142 with the Hoyer lift into bed. Interview on 3/17/23 with Staff D (LNA) revealed that he/she was called to the resident's room and directed by Staff A to assist Staff C with transferring Resident #142 off the floor and into bed. Standard Journal of Nursing; AJN, November 2007 Vol. 107, No. 11. Retrieved from https://www.nursingcenter.com/pdfjournal?AID=751198&an=00000446-200711000-00030&Journal_ID=54030&Issue_ID=751137 on 10/30/20: When a Fall Occurs Step one: assessment. When a patient falls, don't assume that no injury has occurred-this can be a devastating mistake. Before moving the patient .Observe the leg rotation, and look for hip pain, shortening of the extremity, and pelvic or spinal pain. From Merck Manual Consumer Version, Hip Fractures by [NAME], MD, University of San Francisco - Fresno last modified [DATE]. Retrieved from https://www.merckmanuals.com/home/injuries-and-poisoning/fractures/hip-fractures?query=hip%20fracture on 10/30/20: Hip fractures usually occur in older people and often result from minor falls, particularly in people with osteoporosis .Hip fractures are usually very painful and usually cause pain in the groin .However, if the broken pieces have been jammed together and the fracture is small, people can sometimes walk and may have only mild pain, and the leg appears normal .Sometimes when the hip is broken, pain seems to come from the knee instead of the hip. It feels that way because the knee and the hip share part of the same nerve pathways. Such pain is called referred pain.

Based on observation, interview, and policy review it was determined that the facility failed to ensure that medications were secured in the medication cart for 1 out of 2 medication carts observed. Findings include: Observation on 3/15/23 at 10:15 a.m. of the [NAME] Hall medication cart, which contained resident medications, revealed that the cart was unlocked and accessible to staff, visitors, and residents. Interview on 3/15/23 at 10:18 a.m. with Staff I (Registered Nurse) confirmed that the medication cart was not locked. Further interview revealed that Staff I was in the kitchenette getting some supplies and did not lock the cart prior to walking away. Reviewed on 3/15/23 of the facility policy dated 12/01/07 and a revision date of 07/21/22 revealed .Procedure .3.3 Facility should ensure that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors