Health inspection·December 9, 2022

F 0623 Level of Harm - Minimal harm or potential for actual harm to transfer the resident to the emergency room due to possible stroke. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization. 5. Resident #413 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation, non-Hodgkin lymphoma and history of Corona Virus Disease-2019. Residents Affected - Some Review of resident #413's medical record revealed he was hospitalized on [DATE]. A progress note dated 11/09/22 indicated the resident was transferred to the emergency room due to low oxygen saturation levels. The medical record did not contain a Notification of Transfer or Discharge form for the hospitalization. On 12/09/22 at 1:00 PM, the Social Services Director (SSD) stated she was not responsible for completing the Notice of Transfer or Discharge form for hospitalization. She explained the nurses completed the form and then provided a copy to social services to send to the Ombudsman. The SSD reported she had not received any Notice of Transfer or Discharge forms from the nursing department since February 2022. On 12/09/22 at 1:15 PM, the Director of Clinical Services stated the nurses were required to complete the Notice of Transfer or Discharge form when a resident was transferred to the hospital. He acknowledged the nurses had not completed the forms as required. On 12/09/22 at 2:44 PM, the Regional Director of Clinical Services reported the facility was unable to locate Notice of Transfer or Discharge forms for the identified residents who were hospitalized . The facility's policy and procedure for Transfer/Discharge Notification and Right to Appeal revised 10/24/22 read, Before a center transfers or discharges a resident the location must: Notify the resident and resident representative(s) of the transfer or discharge and the reason for the move in writing (in a language and manner they understand). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106029 If continuation sheet Page 2 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete quarterly elopement assessments for 1 of 2 residents reviewed for Accidents out of a total sample of 43 residents, (#30). Residents Affected - Few Findings: Review of resident #30's medical record documented she was admitted to the facility on [DATE] with diagnoses of dementia, paranoid schizophrenia, and cognitive communication deficit. Review of the Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE] noted she had severe cognitive impairment and exhibited wandering behaviors in the past 4-6 days. Review of the physician orders showed an order dated 04/12/22 to place electronic monitoring device on her right ankle and to check for placement on every shift. Review of the plan of care initiated 04/12/22 revealed the resident was an elopement risk related to history of attempts to leave the facility unattended and an electronic monitoring device was placed on her right ankle. Review of the 11/14/22 psychiatric evaluation noted resident #30 was assessed on 10/25/22 and she continued to wander around the facility and entered other resident's rooms. The last time the resident had exit seeking behaviors was in 08/2022. On 12/06/22 at 9:57 AM, resident #30 was observed sitting in a chair in her room and had an electronic monitoring device on her right ankle. The resident explained the device on her ankle was placed so she would not get out of the facility. I have not tried to get out of the facility. On 12/08/22 at 9:38 AM, resident #30 was observed ambulating in her room and had the electronic monitoring device on her right ankle. On 12/09/22 at 9:17 AM and 10:18 AM, the resident stated she could walk in the halls and could go out to the courtyard but she could not leave the facility because of the thing on her ankle. Review of resident #30's medical record revealed an Elopement Risk Evaluation completed on 04/12/2022. The evaluation determined the resident was at risk for elopement. The medical record contained no other Elopement Risk Evaluations. On 12/08/22 at 3:17 PM, the Regional Nurse Consultant stated a resident with an electronic monitoring device was required to have quarterly Elopement Risk Evaluations to determine the need for continued electronic monitoring. She reviewed resident #30's medical record and stated the resident had an active order for the electronic monitoring device and had not had the quarterly Elopement Risk Evaluations completed as required in 08/2022. She indicated another elopement risk evaluation was due this month. Review of the Facility's Elopement/Wandering Risk Guideline Policy and Procedure, dated 0801/2020, read, Overview: To evaluate and identify patients/residents that are at risk for elopement and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106029 If continuation sheet Page 3 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 develop individualized interventions. Process: Patients/Residents to be evaluated on admission, re-admission, 7 days post admission, quarterly . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106029 If continuation sheet Page 4 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to initiate a Preadmission Screening and Resident Review (PASARR) Level I following identification of a severe mental health diagnosis for 1 of 5 residents reviewed for PASARR out of a total sample of 43 residents, (#96). Findings: Review of resident #96's medical record revealed he was admitted to the facility on [DATE] with diagnoses including surgical left above knee surgical amputation, schizoaffective disorder, major depressive disorder, and dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] documented he had moderate cognitive impairment and active diagnoses of dementia, depression and schizophrenia. Review of the plan of care showed individualized care plans for the use of antidepressant medication initiated on 08/19/22, psychotropic medication use initiated on 08/28/22, and behaviors for refusing medications, bath/shower and refusing to wear his stump shaper for his recent left above knee amputation. Review of the physician's order summary dated 03/01/22-12/31/22 revealed an order dated 03/23/22 for Seroquel 25 milligrams (mg) give 0.5 tablet by mouth (po) at bedtime for depression and then on 03/24/22 the order was changed to Seroquel 25 mg give 0.5 tablet by mouth at bedtime for depression for 10 days. On 08/18/2022 Wellbutrin 150 mg po two times a day (bid) for depression and Quetiapine 12.5 mg po at bedtime for abnormal thoughts. Review of the pre-admission PASARR Level 1 Screen completed on 03/09/2022 by the acute care hospital Registered Nurse (RN) revealed no documentation of the resident's diagnoses of depressive or schizoaffective disorders. The form indicated resident #96 had no primary diagnosis of dementia. Review of Psychiatric Notes dated 06/20/22 documented psychiatric history was obtained from his family. The notes read, significant history of psychiatric hospitalizations, and prior psychiatric treatment with diagnoses of Schizophreniform, Dementia, and Depression. Patient continues to tolerate current psychiatric medications without complication. The resident was seen on 06/28/22, 08/08/22, 08/19/22 (readmission Evaluation), 08/23/22, 09/27/22, 10/25/22 (Medication Review) and on 11/04/22. On 12/08/22 at 1:27 PM, the Director of Nursing (DON) explained if a resident's pre-admission PASARR did not indicate Mental Illness (MI) or Intellectual Disability (ID) and if the facility identified diagnoses for MI and/or ID, we need to complete a new PASARR Level I. The DON reviewed resident #96's medical record and stated the resident had diagnoses listed on the PASARR Level 1 form for MI and there was no PASARR Level 1 completed by the facility. The DON noted, A new PASARR Level should have been completed for resident #96. On 12/08/22 at 3:18 PM, the Regional Nurse Consultant (RNC) stated, Resident #96 should have had a new PASARR Level I completed once the facility identified his severe mental health diagnosis of Schizophrenia. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106029 If continuation sheet Page 5 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Facility's Preadmission Screening and Resident Review (PASARR) Policy and Procedure, revision dated 11/08/2021, read, Policy: The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screening according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive care and services they need in the most appropriate setting . Procedure: . 3. There are no exceptions for Intellectually Disabled (ID) screenings. 4. If it is leaned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. Event ID: Facility ID: 106029 If continuation sheet Page 6 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen concentrator filters were maintained to ensure quality of oxygen flow for 2 of 2 residents reviewed for Respiratory Care out of a total sample of 43 residents, (#5, #77). Residents Affected - Few Findings: 1. Review of resident #5's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease (COPD) and dependence on supplemental oxygen. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented she was cognitively intact and received oxygen therapy. Review of resident #5's plan of care documented potential for altered respiratory status/difficulty breathing related to chronic respiratory failure initiated on 06/15/22. The goal indicated she will have minimal risk of poor oxygen absorption. On 08/31/22 a care plan for oxygen therapy was initiated with interventions to provide oxygen as ordered. Review of the physician's orders documented an order dated 12/02/22 for continuous oxygen at 2 liters (L) by nasal cannula (NC). On 12/06/22 at 10:39 AM and 12/08/22 at 9:43 AM, resident #5 was observed with oxygen at 2 L NC via oxygen concentrator. The oxygen concentrator filter was noted to be covered with gray dust . On 12/08/22 at 9:48 AM, an observation of resident #5's oxygen concentrator was conducted with the Williamsburg Unit Manager. The Unit Manager removed the filter from the back of the oxygen concentrator and picked the gray dust off the filter. He stated, The oxygen concentrator filters should be free of dust to ensure proper oxygen flow to the resident. 2. Review of resident #77's medical record documented she was admitted to the facility on [DATE] with diagnosed including Acute and Chronic Respiratory Failure with Hypoxia, Pneumonia, Acute Bronchospasm, and dependence on supplemental oxygen. Review of the 5 day Medicare Minimum Data Set (MDS) assessment dated [DATE] noted she was cognitively intact and received oxygen therapy. Review of resident #77's care plan for oxygen therapy initiated on 11/29/22 noted the goal was for the resident to be free from signs and symptoms of poor oxygen absorption and interventions included to provide oxygen as ordered. Review of the physician's orders documented an order dated 11/19/22 for continuous oxygen at 3 L via NC. On 12/06/22 at 10:39 AM and 12/08/22 at 9:48 AM, resident #77 was observed on oxygen at 3 L by NC. The oxygen concentrator filter was noted to be covered with gray dust. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106029 If continuation sheet Page 7 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/08/22 at 9:51 AM, observation of resident #77's oxygen concentrator filter was conducted with the UM. The UM peeled gray dust from the oxygen concentrator filter and stated, the nurses are responsible for checking and cleaning the oxygen concentrator filters. On 12/08/22 at 9:53 AM, Registered Nurse (RN) A explained nurses were responsible for changing the oxygen tubing and cleaning the oxygen concentrator filters on Fridays. She stated, The filters are to be clean in order to filter room air entering the concentrator and to ensure proper oxygen flow to the resident. Review of the Facility's Oxygen Therapy Policy and Procedures, revision date 08/28/2017, read, Policy: Oxygen therapy is the administration of Fraction of inspired oxygen (FIO2) greater than 21% by means of various administration devices to . treat arterial hypoxemia, to decrease work of breathing, to reverse and prevent tissue hypoxia and/or decrease myocardial work, Equipment: The selection of an appropriate oxygen delivery device is based on the FIO2 necessary to reduce or correct hypoxemia, resident comfort and is practical to use for that individual . Procedure: Physician's order for oxygen therapy shall include administration modality, FIO2 or liter flow, continuous or as needed (PRN). Review of the Facility Assessment Tool documented the facility was able to care for residents with diseases of the respiratory system requiring oxygen therapy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106029 If continuation sheet Page 8 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #16 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, schizoaffective disorder, and Type 1 diabetes mellitus. The annual Minimum Data Set assessment dated [DATE] revealed resident #16 received insulin, antidepressant and opioid medications during the 7 days lookback period. Resident #16 had care plans for use of antipsychotic medications, and antidepressant medications with interventions for staff to administer the medications as ordered by the physician and to evaluate medication use and response quarterly. Review of the Order Summary Report for active orders as of 12/09/22 revealed physician orders for resident #16 included Gabapentin Capsule 300 milligrams (MG) three times a day for nerve pain, Quetiapine Fumarate 200 MG, once a day at bedtime for schizoaffective disorder and Hydrocodone-Acetaminophen tablet 5-325 MG, give 1 tablet every 4 hours as needed for non-acute pain. Review of a Consultation Report from the consulting pharmacist dated 11/01/22 through 11/03/22 revealed the recommendation for the physician to consider avoiding or minimizing the use of the combination of the Hydrocodone-Acetaminophen with the Quetiapine Fumarate and the Gabapentin. The pharmacy recommendation reported the combination of the medications increased the risk of toxicity and overdose, and the Federal Drug Administration issued a BOXED WARNING that health care professionals should limit prescribing opioid pain medicines with other Central Nervous System (CNS) depressants unless alternative treatment options were inadequate. The recommendation also noted that use of opioid medications in combination with other CNS depressants might mask the signs or symptoms of overdose, and if prescribed the minimum dose and duration of each drug needed to maintain the desired clinical effect should be used. The report provided a section for resident #16's physician to respond by marking the recommendations as accepted, accepted with modifications listed or declined. The last section of the report was for the physician's signature and date. On 12/09/22 12:40 PM, the Unit Manager stated the Director of Clinical Services received the pharmacy recommendations monthly and gave them to her after they were signed by the physician. She would then implement any new orders made by the physician. On 12/09/22 at 12:26 PM, the Regional Nurse consultant stated the facility could not provide the physician's response to resident #16's pharmacy recommendation for November 2022. On 12/09/22 at 12:46 PM, the Director of Clinical Services stated the pharmacy sent him the pharmacy recommendations monthly in an email. He explained he printed them and put them in the physician's mailbox for review and signature. He stated resident #16's physician did not come to the facility as often and the pharmacist's recommendation from November 2022 was found in his mailbox, unchecked and unsigned. In a telephone interview on 12/09/22 at 1:06 PM, the consulting Pharmacist stated he did the monthly medication recommendations for the facility. He explained he checked the facility census to review each resident's current status in regard to their medications. He stated every resident in the facility should be reviewed for their medications at least once per month. He explained he emailed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106029 If continuation sheet Page 9 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 106029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at Lake Mary 710 North Sun Drive Lake Mary, FL 32746 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few monthly recommendations to the Director of Clinical Services and followed up on his next visit to the facility. The consulting Pharmacist stated he could not find a response for resident #16's November 2022 recommendations. He explained there were new guidelines by the Federal Drug Administration and so the recommendations were made for residents who were prescribed opioid medications. He explained the purpose of the pharmacy recommendations were to make the physicians aware of the medications and any potential risks to prevent adverse events from happening and for the improved safety of the residents. The policy and procedure, Monthly Drug Regimen Review with revision date 10/10/18 revealed the procedures that should be implemented for the monthly drug regimen review by the Director of Clinical Services. The document provided direction for the Director of Clinical Services to discuss with the consulting Pharmacist the recommendations not responded to by the physician and develop a plan for completing them. The procedures also included direction for the Director of Clinical Services to complete follow-up as indicated with the Medical Director if there was no response from the attending physician. Based on interview, and record review, the facility failed to ensure a pharmacy Medication Regimen Review (MRR) was completed for 1 of 5 residents, (#17) and failed to ensure physician acted upon pharmacy recommendation for 1 of 5 residents, (#16) reviewed for Unnecessary Medication Review out of a total sample of 43 residents. Findings: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, chronic pain, major depressive disorder, convulsions, atrial fibrillation, and long-term use of insulin. Review of the pharmacy Consultation Summary Report for March 1, 2022 to March 31, 2022, revealed a medication review was not conducted for resident #17. On 12/09/22 at 12:40 PM, the Unit Manager stated the Director of Clinical Services received the monthly pharmacy reports and recommendations. On 12/09/22 at 12:46 PM, the Director of Clinical Services reviewed the facility's medication reviews for March 2022 and stated, I don't see his name here, referring to resident #17. He explained the process for reviewing reports was to ensure all residents' medications were reviewed monthly by the Consultant Pharmacist. On 12/09/22 at 1:06 PM, the Pharmacy Consultant stated he was responsible for conducting the monthly medication regimen review for the facility. He explained the process included accessing the facility electronic medical records (EMR) to retrieve a census of active residents. He validated there was no medication review completed for resident #17 in March 2022. The Pharmacy Consultant explained a monthly medication review was necessary to ensure, the resident's safety by assisting and informing the provider to be able to make better decisions for the resident's care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106029 If continuation sheet Page 10 of 10