Based on staff interview and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for two of 14 residents in the survey sample, Residents #7 and 22. The findings include: 1. For Resident #7 (R7), the facility staff failed to revise the care plan when the resident developed a pressure ulcer. A review of R7's clinical record revealed the resident was receiving treatment for a pressure ulcer. The record contained the following physician's order: Sodium Hypochlorous Acid (Vashe Wound Cleanser) 0.333% Once per day [for pressure ulcer] on Monday, Wednesday, Friday. A review of R7's April 2023 TAR (treatment administration record) revealed the resident was receiving the pressure ulcer treatments as ordered. A review of R7's care plan updated 3/1/23 revealed, in part: 11/22/21 Resident will not experience redness or skin breakdown over the next 90 days. However, the care plan had not been updated to address R7's actual pressure ulcer. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated she is responsible for updating the care plan, and it should include the development of a pressure ulcer. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated the MDS nurse updates the care plans for the facility's residents. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. On 4/20/23 at 8:55 AM an interview was conducted with ASM #2. When asked about the care plan not being revised to address the development of the pressure injury, ASM #2 stated that it should be, and that being under a new healthcare system and a new electronic medical record system was a learning process for the facility. A policy was requested for reviewing and revising the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. 2. For Resident #22 the facility staff failed to review and revise the comprehensive care plan to address the development of an actual pressure wound and the associated treatments. A review of the clinical record revealed a nurse's note dated 8/29/22 that documented, Pt (patient) has pressure injury to sacrum that appears to be a stage 2. NP (nurse practitioner) at bedside to visualize . A review of the physician's orders revealed the following: 1. Dated 1/25/23 for Please use wedge to position (Resident #22) off of [their] back. Side lying only to avoid sacral pressure. 2. Dated 3/13/23 for wound care daily to sacrum for Vashe moistened packing strips for appropriate moisture and antimicrobial activity. Mepilex border/sacral to manage exudate and for cover dressing. Change dressing daily. A review of the comprehensive care plan revealed the following one dated 11/22/21 for Potential for loss of skin integrity secondary to: impaired mobility, incontinence, gastrostomy and/or jejunal tube site, tracheostomy tube site, prolonged wheelchair seating, splint/AFO's/TLSO braces, less/more than ideal body weight, contracture lower extremities, peri-area r/t (related to) intermittent catheterizations, eye irritation, scratching face. The interventions, dated 11/22/21 documented, Assess all skin surfaces with bathing, attends changes. Use appropriate ointments, creams and lotions. Keep peri-area clean and dry. Change attends every 4 hours and prn (as needed). Assess skin for pressure and redness with position changes, after splint removal, and after wheelchair seating. Assess g-tube and trach site with routine care. Document bruising and/or reddened areas and report to therapies and MD (medical doctor) for evaluation and/or treatment. Report wheelchair equipment needs for evaluation and repair to therapy or equipment provider. Advise family of noted skin breakdown or injuries incurred. Document any changes in status of skin surfaces involve and report to MD/therapy. MOM's Magic Paste for reddened areas as ordered. Keep nails trimmed to prevent scratching. Further review of the comprehensive care plan failed to reveal any evidence that the care plan was reviewed and revised to address an actual pressure injury that developed and associated treatments and interventions. On 4/19/23 at 10:57 AM, an interview was conducted with RN #1 (registered nurse), the MDS nurse. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. She stated the entire interdisciplinary team has access to the care plans. On 4/19/23 at 12:05 PM, an interview was conducted with LPN #1 (licensed practical nurse). She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. On 4/19/23 at 1:50 p.m., ASM (Administrative Staff Member) #1, the Administrator, ASM #2, the Director of Performance Management, and ASM #3, the Director of Nursing, were made aware of the findings. On 4/20/23 at 8:55 AM an interview was conducted with ASM #2. When asked about the care plan not being revised to address the development of the pressure injury, ASM #2 stated that it should be, and that being under a new healthcare system and a new electronic medical record system was a learning process for the facility. A policy was requested for updating care plans, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided by the end of the survey.

Based on observation, staff interview, and clinical record review, the facility staff failed to apply orthotic devices as ordered for two of 14 residents in the survey sample, Residents #19 and #16. The findings include: 1. For Resident #19 (R19), the facility staff failed to apply bilateral (both left and right) AFOs (ankle/foot orthoses) (devices for positioning of the ankle/foot) when the resident was out of bed. On 4/19/23 at 9:53 a.m., R19 was sitting in a wheelchair in the facility school room. R19 did not have any positioning devices on his feet or ankles. RN (registered nurse) #2 stated the resident was not wearing an AFO at that moment, and that the staff would put the AFOs on if the resident was positioned in a stander. A review of R19's physician orders revealed, in part: 9/19/22 Apply brace Bilateral AFO until discontinued. Comments: Pt (patient) should wear B (bilateral) AFOs from 8 am - 4 pm when OOB (out of bed) or when in stander. A review of R19's care plan revealed, in part: 11/22/21 Resident will have mobility within the limits of disease .Keep limbs in functional alignment using pillows, wedges, or splints as ordered. On 4/19/23 at 12:00 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated there is a communication book at the nurses' station with information about AFOs for each resident. She stated each resident also has a binder inside their closet door with the AFO information there, as well. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated she was responsible for taking care of R19 that day. She stated she checks the physician orders to make sure what AFOs have been ordered by the physician. She stated she was not certain whether or not R19 had been wearing AFOs that morning. She stated sometimes the staff decides to give give the resident a rest from the orthotics. She stated there was no order to do so, and no place to document why this was not being done. On 4/19/23 at 12:57 p.m., RN #2 stated sometimes R19 will not tolerate the AFOs, and they are not applied by the staff. She stated the system does not allow the staff to document a resident's refusal or intolerance. She stated CNAs (certified nursing assistants) are primarily responsible for applying the AFOs, and should alert the nurse if the resident is not tolerating the braces well. She stated the nurse should write a progress note. She stated she could not find where this had been done for R19. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for implementing physician-ordered orthotic devices, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. 2. For Resident #16 (R16), the facility staff failed to apply bilateral (both left and right) hand splints as ordered by the physician. On 4/18/23 at 1:56 p.m., R16 was lying in bed, and was not wearing hand splints. On 4/19/23 at 9:52 a.m., R16 was sitting in a wheelchair in the facility school room. The resident was not wearing hand splints. A review of R16's physician orders revealed, in part: 3/25/23 Apply splint Bilateral: Resting Hand Splint Until discontinued. Pt (patient) to wear bilateral .hand splints from 8 am - noon and 1 pm - 4 pm. A review of R16's care plan did not reveal any information related to the bilateral hand splints. On 4/19/23 at 12:00 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated there is a communication book at the nurses' station with information about braces and splints for each resident. She stated each resident also has a binder inside their closet door with the information there, as well. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated she was responsible for taking care of R16 that day. She stated she checks the physician orders to make sure what splints have been ordered by the physician. She stated she was not certain whether or not R16 had been wearing hand splints that morning. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for implementing physician-ordered orthotic devices, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit.

Based on observation, staff interview, and clinical record review, it was determined that the facility staff failed to develop and/or implement a care plan for five of 14 residents in the survey sample, Residents #19, #16, #29, #30, and #10. The findings include: 1. For Resident #19 (R19), the facility staff failed to implement the care plan for the use of bilateral (both left and right) AFOs (ankle/foot orthoses-which are devices for positioning of the ankle/foot). On 4/19/23 at 9:53 a.m., R19 was sitting in a wheelchair in the facility school room. R19 did not have any positioning devices on their feet or ankles. RN (registered nurse) #2 stated the resident was not wearing an AFO at that moment, and that the staff would put the AFOs on if the resident was positioned in a stander. A review of R19's physician orders revealed, in part: 9/19/22 Apply brace Bilateral AFO until discontinued. Comments: Pt (patient) should wear B (bilateral) AFOs from 8 am - 4 pm when OOB (out of bed) or when in stander. A review of R19's care plan revealed, in part: 11/22/21 Resident will have mobility within the limits of disease .Keep limbs in functional alignment using pillows, wedges, or splints as ordered. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. She stated the entire interdisciplinary team has access to the care plans. She stated R19's care plan was not being followed if the resident was not wearing the AFOs when out of bed. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated the care plan should always be followed. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for developing/implementing the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. 2. For Resident #16 (R16), the facility staff failed to implement the care plan for the resident's use of bilateral hand splints. On 4/18/23 at 1:56 p.m., R16 was lying in bed, and was not wearing hand splints. On 4/19/23 at 9:52 a.m., R16 was sitting in a wheelchair in the facility school room. The resident was not wearing hand splints. A review of R16's physician orders revealed, in part: 3/25/23 Apply splint Bilateral: Resting Hand Splint Until discontinued. Pt (patient) to wear bilateral .hand splints from 8 am - noon and 1 pm - 4 pm. A review of R16's care plan revealed, in part: 11/22/21 Resident will have mobility within the limits of disease .Keep limbs in functional alignment using pillows, wedges, or splints as ordered. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. She stated the entire interdisciplinary team has access to the care plans. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated the care plan should always be followed. She stated R16's care plan was not being followed for the hand splints. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for developing/implementing the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. 3. For Resident #29, the facility staff failed to develop a care plan for the administration of Diazepam (1). A review of R29's physician's orders revealed, in part: 1/24/23 Diazepam solution 0.21 mg/kg (milligrams per kg (kilograms) 1.5 mg per G tube (feeding tube) every 6 hours. The medication was ordered to treat the symptoms of the resident's genetic abnormalities. A review of R29's April 2023 MAR (medication administration record) revealed the resident received the Diazepam as ordered. A review of R29's comprehensive care plan failed to reveal information related to the administration or monitoring of the Diazepam. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. When asked if a high-risk medication like Diazepam should be care planned, she stated: Yes. RN #1 confirmed R29's care plan did not include information related to the risks of Diazepam. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated high-risk medications should have a care plan. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. A policy was requested for developing/implementing the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided prior to exit. (1) Diazepam is used to relieve anxiety and to control agitation caused by alcohol withdrawal. It is also used along with other medications to control muscle spasms and spasticity caused by certain neurological disorders such as cerebral palsy (condition that causes difficulty with movement and balance), paraplegia (inability to move parts of the body), athetosis (abnormal muscle contractions), and stiff-man syndrome (a rare disorder with muscle rigidity and stiffness). This information is taken from the website https://medlineplus.gov/druginfo/meds/a682047.html. 4. For Resident #30 (R30), the facility failed to develop a plan for the administration of Lispro (1) (a medication used for the treatment of diabetes). A review of R30's physician's orders revealed, in part: 10/21/22 Insulin Lispro (Humalog) 100 units/ml (milliliter) injection. Give 1-7 units per sliding scale. A review of R30's April 2023 MAR (medication administration record) revealed the resident received the medication as ordered. A review of R30's care plan failed to reveal information related to the administration or monitoring of the Lispro. On 4/19/23 at 10:57 a.m., RN (registered nurse) #1, the MDS nurse, was interviewed. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. When asked if a high-risk medication like Lispro should be care planned, she stated: Yes. RN #1 confirmed R30's care plan did not include information related to the risks of Lispro. On 4/19/23 at 12:05 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. She stated high-risk medications should have a care plan. On 4/19/23 at 1:50 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of performance management, and ASM #3, the director of nursing, were informed of these concerns. No further information was provided prior to exit. A policy was requested for developing/implementing the care plan, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. (1) HUMALOG (Lispro) is a rapid acting human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus. This information is taken from the website https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=c8ecbd7a-0e22-4fc7-a503-faa58c1b6f3f. 5. For Resident #10, the facility staff failed to develop a care plan to address safety needs, including the use of side rails. On 4/18/23 at 6:57 AM, 4/19/23 at approximately 11:00 AM, and 4/20/23 at approximately 8:00 AM, Resident #10 was observed in bed, with side rails up on both sides. A review of the clinical record revealed an order dated 11/30/21 for Side rails up x4. A Consent for use of side rails dated 10/26/17 documented, the resident was to have full side rails on left and right sides, and was recommended at all times when the resident was in bed. The purpose of the side rails was documented as Fall Risk. Risks and benefits were documented on the consent. A review of the comprehensive care plan failed to address any safety needs for Resident #10, including the fact that they were a fall risk, and for the use of side rails. On 4/19/23 at 10:57 AM, an interview was conducted with RN #1 (registered nurse), the MDS nurse. She stated a resident's care plan should contain information regarding head to toe systems for each resident. She stated the care plan should cover safety, falls, nutrition, special equipment, bowel elimination, dehydration, fluid maintenance, communication, and anything having to do with a residents ADLs (activities of daily living). She stated the EMR (electronic medical record) software has a care plan template. This template includes a list of goals and interventions from which she can choose as she develops the individualized care plan. She stated she has primary responsibility for developing the resident's care plan following the initial MDS (minimum data set) assessment after a resident is admitted . She stated she is also primarily responsible for updating the care plans with new problems and new interventions. She stated the purpose of a care plan is to give the residents the best possible care. She stated the entire interdisciplinary team has access to the care plans. On 4/19/23 at 12:05 PM, an interview was conducted with LPN #1 (licensed practical nurse). She stated the purpose of a care plan is to make sure everyone knows exactly what a resident needs for safety, and for overall care. On 4/19/23 at 1:50 p.m., ASM (Administrative Staff Member) #1, the Administrator, ASM #2, the Director of Performance Management, and ASM #3, the Director of Nursing, were made aware of the findings. On 4/20/23 at 8:55 AM an interview was conducted with ASM #2. When asked about not having a care plan to address safety needs and the use of side rails, ASM #2 stated that there wasn't one but that there should have been one. A policy was requested for developing care plans, however none was provided. On 4/20/23 at 12:29 PM, ASM #2 stated the facility did not have the requested policy. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #30 (R30), the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. R30 was admitted to the facility on [DATE]. A review of R30's clinical record revealed all required monthly medication regimen reviews. However, a review of the facility's monthly medication regimen review policy failed to reveal time frames for pharmacist's review and physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the director of nursing, were informed of these concerns. No further information was provided prior to exit. 5. For Resident #29 (R29), the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. R29 was admitted to the facility on [DATE]. A review of R29's clinical record revealed all required monthly medication regimen reviews. However, a review of the facility's monthly medication regimen review policy failed to reveal time frames for the physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 p.m., ASM #1, the administrator, ASM #2, and ASM #3, the director of nursing, were informed of these concerns. No further information was provided prior to exit. Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to develop a Medication Regimen Review policy that included required time frames for pharmacist's review and physician's response to the pharmacist's recommendations, for five of 14 residents in the survey sample; Residents #22, #8, #10, #30, and #29. The findings include: 1. For Resident #22 the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. A review of the clinical record revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility's monthly medication regimen review policy, dated 2/27/23, failed to reveal time frames for pharmacist's review and physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 PM, ASM #1, the Administrator, ASM #2, and ASM #3, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 2. For Resident #8 the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. A review of the clinical record revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility's monthly medication regimen review policy, dated 2/27/23, failed to reveal time frames for pharmacist's review and physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 PM, ASM #1, the Administrator, ASM #2, and ASM #3, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey. 3. For Resident #10, the facility staff failed to ensure the medication regimen review policy contained required time frames for pharmacist's review and physician's response. A review of the clinical record revealed all required monthly medication regimen reviews and no concerns were identified. However, a review of the facility's monthly medication regimen review policy, dated 2/27/23, failed to reveal time frames for pharmacist's review and physician's response. A review of the facility policy Policy on Medication Regimen Review, dated 2/27/23 failed to document any time frames, including when the physician is to act upon pharmacy recommendations. On 4/19/23 at 11:36 a.m., ASM (administrative staff member) #2, the director of performance management, stated, We don't have anything else. On 4/19/23 at 1:50 PM, ASM #1, the Administrator, ASM #2, and ASM #3, the Director of Nursing, were made aware of the findings. No further information was provided by the end of the survey.