**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) after a new mental health diagnosis for 1 resident (#15) of 3 residents reviewed for PASARR. The findings include: Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Anxiety Disorder. Record review of the most recent PASARR Level 1 assessment dated [DATE], revealed Resident #15 had a mental health diagnosis of Anxiety Disorder. Record review revealed Resident #15 received a new problem/ condition of Delusions was added on 12/14/2022. Record review revealed no new Level II PASARR had been submitted to include a new diagnosis/ condition of Delusions with anti-psychotic medication use. Record review revealed a care plan had been initiated on 12/14/2022 for psychotropic medication use for Delusions . Review of the quarterly Minimum Data Assessment (MDS) dated [DATE], revealed Resident #15 had an active diagnosis of .Anxiety .Depression .Psychotic Disorder . and received antipsychotic, antianxiety, and antidepressant medications during the last 7 days. During an interview on 8/7/2023 at 7:52 AM, the Director of Nursing stated when a resident in the facility receives a new mental health diagnosis a PASSAR was to be resubmitted for the resident. During an interview 8/7/2023 at 8:11 AM, in the MDS office, the MDS Coordinator stated she was responsible for PASARR updates and confirmed the PASARR for Resident #15 was submitted to after a new diagnosis/ condition of Delusions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to ensure the Physician reviewed and acted upon irregularities identified by the Consultant Pharmacist for 2 residents (#30 an #32) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy, Medication Regimen Reviews, revised 5/2019 revealed .The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports .Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record . Record review showed Resident #30 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Failure to Thrive, Dementia, and Major Depressive Disorder. Review of a Consultation Report dated 3/30/2023 showed .[Resident #30] .psychotropic .w/o (with out) documentation of a specific diagnosis and benefit to the resident . Continued review revealed the Physician signed 6/15/2023 but did not respond to the Consultant Pharmacist recommendation. Review of a Consultation Report dated 6/29/2023 showed .[Resident #30] .psychotropic .w/o (with out) documentation of a specific diagnosis and benefit to the resident . Continued review revealed the Physician had not signed or responded to the Consultant Pharmacist recommendation. Record review showed Resident #32 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Chronic Kidney Disease. Review of a Consultation Report dated 3/30/2023 showed .[Resident #32] .chronic long term use of .narcotic .w/o documentation of specific diagnosis and benefit to the resident . Continued review revealed the Physician had not signed or responded to the Consultant Pharmacist recommendation. Review of a Consultation Report dated 4/27/2023 showed .[Resident #32] .chronic long term use of .narcotic .w/o documentation of specific diagnosis and benefit to the resident . Continued review revealed the Physician had not signed or responded to the Consultant Pharmacist recommendation. Review of a Consultation Report dated 5/25/2023 showed .[Resident #32] .chronic long term use of .narcotic .w/o documentation of specific diagnosis and benefit to the resident . Continued review revealed the Physician had not signed or responded to the Consultant Pharmacist recommendation. Review of a Consultation Report dated 6/29/2023 showed .[Resident #32] .chronic long term use of .narcotic .w/o documentation of specific diagnosis and benefit to the resident . Continued review revealed the Physician had not signed or responded to the Consultant Pharmacist recommendation. Interview with the Director of Nursing (DON) on 8/8/2023 at 8:22 AM, in the DON office, revealed the Physician's were in the facility at least monthly to review reports. Continued interview with the DON confirmed the Consultant Pharmacist recommendations were not acted upon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to ensure a PRN (as needed) anti-psychotic medication was not used beyond 14 days without a rationale and without documentation of duration for 1 resident (Resident #15) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Antipsychotic Medication Use dated July 2022, revealed .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time .PRN orders for antipsychotic medications will not be renewed beyond 14 days .the duration of the PRN order will be indicated on the order . Record review revealed Resident #15 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder and Anxiety Disorder. Review of a Physician's order dated 5/11/2023, revealed an order for Seroquel (anti-psychotic medication) 25 milligrams (mg) every 24 hours PRN for anxiety/agitation. The order did not have a date the medication was to be discontinued. Review of the quarterly Minimum Data Assessment (MDS) dated [DATE], revealed Resident #15 had an active diagnosis of .Anxiety .Depression .Psychotic Disorder . and received antipsychotic, antianxiety, and antidepressant medications. Review of an After Visit Summary dated 5/11/2023, revealed an order for Seroquel 25 mg every 24 hours PRN for agitation, with no documentation of when the medication was to be discontinued. Review of the Psychiatric Periodic Evaluation dated 7/12/2023, revealed Seroquel 25mg Q24H (every 24 hours) was an active medication with current recommendations to continue medication with no stop date documented. During an interview on 8/7/2023 at 2:04 PM, the Director of Nursing (DON) stated Resident #15's order for PRN Seroquel should have been discontinued after readmission into facility from her hospital stay. The DON stated the hospital had changed Seroquel from scheduled to PRN and the medication reconciliation was missed post readmission. Further interview revealed it is not the facility's practice to have anti-psychotic medications ordered for PRN use. During an interview on 8/8/2023 at 8:52 AM, in the DON office, the DON confirmed the PRN Seroquel order should have been discontinued and was ordered for longer than 14 days without a rationale and without a specified duration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and interview, the facility failed to ensure laboratory (lab) tests were obtained for 1 resident (Resident #33) of 16 residents reviewed for laboratory results. Findings include: Review of the facility's policy titled, Lab and Diagnostic Test Results-Clinical Protocol dated November 2018, revealed The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs .staff will process test requisitions and arrange for test . Review of the admission Record revealed Resident #33 was admitted to facility on 3/7/2022 with diagnosis of Atrial Fibrillation. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #33 had an active diagnosis of atrial fibrillation and received anti-coagulant medication 7 of 7 days. Review of the current care plan dated 3/7/2022, revealed Resident #33 was on anticoagulant therapy with interventions for labs as ordered. Review of Order Summary dated 8/8/2023, revealed orders for Coumadin 7.5mg (milligram) daily on Wednesdays and Fridays for a-fib (atrial fibrillation) and Coumadin 5mg daily on Monday, Tuesday, Thursday, Saturday, and Sunday for a fib. Review of a physician's order dated 6/23/2023, revealed an order to Redraw PT/ INR (blood test that measures blood clotting) 2 weeks from 6-22-23 on 7-5-23. Review of laboratory results for Resident #33 revealed the most recent PT/INR results were dated 6/22/2023. During an interview on 8/7/2023 at 1:31 PM, the Director of Nursing (DON) stated there was no results in the medical record for the PT/INR ordered on 7/5/2023. The DON stated the last PT/ INR obtained was on 6/22/2023. During an interview on 8/7/2023 at 2:01 PM, the DON confirmed Resident #33's PT/INR was missed on 7/5/2023 because it did not trigger on the MAR (Medication Administration Record) for the floor nurse to obtain the lab . During an interview on 8/7/2023 at 2:29 PM, the resident's Primary Physician stated Resident #33 is stable on Coumadin therapy with a history of stability while taking the medication. The resident's Primary Physician stated he was not concerned the lab draw was missed on 7/5/2023 . gave orders for facility to obtain PT/INR on 8/7/2023. The resident's Primary Physician stated the resident has a .history of routinely receiving PT/ INR lab draws monthly, however, in this case the lab (PT/INR) was ordered by an on-call Physician who ordered it sooner . The resident's Primary Physician stated the non-critical PT/ INR lab result for 8/7/2023 of 3.21 was not alarming to him and he would expect to see some INR's range higher for Resident #33. The resident's Primary Physician stated Resident #33 is stable at this time with no adverse effects from the missed lab (PT/INR). During an interview on 8/8/2023 at 8:52 AM, in the conference room, the MDS Coordinator confirmed the lab order did not trigger on the MAR due to a data entry error of not completing the scheduling details portion of the order. The MDS Coordinator stated to get the lab to trigger over to the MAR for floor nurse to obtain the lab, scheduling details of data entry must be completed.