**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for one of 40 sampled residents (R) (R16). This failure had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: Review of the electronic medical record (EMR) for R16 revealed they were admitted to the facility with diagnoses of but not limited to end stage renal disease, type 2 diabetes mellitus without complications acute on chronic diastolic (congestive) heart failure spinal stenosis, cervical region, generalized anxiety disorder, chronic kidney disease, stage 5, anemia in chronic kidney disease, Alzheimer's disease, unspecified, acute embolism and thrombosis of deep veins of left upper extremity, pruritus, unspecified, depression. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R16 documented a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive deficit. Further review of physician orders revealed R16 was prescribed Carvedilol Tab 25 MG (milligram) Give 1 tablet orally two times a day related to Acute or chronic diastolic (congestive) heart failure Pharmacy Active 2/15/2025 17:00 (5:00 pm) 2/17/2025 Supply Clopidogrel Bisulfate Tab 75 MG (Base Equiv (equivalent) Give 1 tablet orally one time a day related to Athscl (atherosclerotic) heart disease of native coronary artery w/o (without) [NAME] pctrs (angina pectoris) Pharmacy Active 2/16/2025. Review of R16's EMR revealed R16 was sent to the hospital on 2/4/2025. Further review revealed there was no bed hold policy notice in the EMR or in the paper chart. During an interview on 3/27/2025 at 2:25 pm with Licensed Practical Nurse (LPN) BB regarding the bed hold policy when a resident was transferred to the hospital, she revealed that Admissions was responsible for sending a resident to the hospital with bed hold policy notice and informing them when the bed hold was going to expire. During an interview on 3/27/2025 at 2:36 pm with the Director of Admissions, she revealed that the bed hold policy notice was included in the admission package upon resident admission. She stated that the resident or their responsible party signed the form at admission, and it stayed in the resident file. She stated that when residents transferred to the hospital, they did not send them out with a bed hold policy notice. She stated that when the business office staff came in the next day, they looked at the midnight census to know which residents transferred to the hospital and then put it in their system. During an interview on 3/27/2025 at 2:40 pm with the Business Office Manager, she revealed they were not responsible for sending out a bed hold policy notice to residents when transferring to the hospital. During an interview on 3/27/2025 at 2:37 pm with the Administrator regarding the facility bed hold policy when transferring to the hospital, she revealed that upon admission the bed hold policy was included with the admission package. She stated they do not send residents with a bed hold policy notice when they transfer to the hospital because they already had one in their chart upon admission. She stated the facility had no policy on bed holds.

Based on observations, resident and staff interviews, record review, and review of the facility policy titled, Comprehensive Person-Centered Care Plans, the facility failed to implement a care plan for oxygen (O2) therapy for one of 10 residents (R) (R53) receiving O2 therapy. The deficient practice had the potential for R53's needs to go unmet. Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans dated January 2025 revealed under Policy: Each resident will have a person-centered plan of Care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Review of the Physician's Orders for R53 revealed an order dated 3/27/2025 for oxygen at 2 liters per minute (LPM) via nasal cannula (NC) as needed for O2 sats (saturations) oxygen in place for R53. Review of R53 care plan revealed a care plan intervention for the use of oxygen set at 2 L (liters). Observation and interview during the initial screening on 3/25/2025 at 10:00 am revealed R53's O2 level was set at 3 LPM. R53 stated that it should be set at 2 LPM. Observation on 3/25/2025 at 03:28 pm revealed R53's O2 level remained set at 3 LPM. Observation on 3/26/2025 at 10:56 am revealed R53's O2 level was still set at 3 LPM. During an interview on 3/26/2025 at 3:52 pm with Licensed Practical Nurse (LPN) AA regarding R53's O2 setting, she stated that the order was for O2 to be set at 2 LPM. During an interview on 3/26/2025 at 5:40 pm with LPN BB, she confirmed that R53's O2 was set at 3 LPM. She went to the EMR and confirmed that the physician order was for O2 to be set at 2 LPM. During an interview on 3/27/2025 at 8:00 am with the Director of Nursing (DON), she revealed that she expected staff to follow and adhere to the physician order and to ensure that during rounds O2 was set at the ordered level

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the electronic medical record (EMR) revealed R53 was admitted to the facility with diagnoses of but not limited to type 2 diabetes mellitus without complications, peripheral vascular disease, unspecified, cardiovascular and coagulations, hereditary and idiopathic neuropathy, unspecified, acute neurologic, gastro-esophageal reflux disease without esophagitis, anemia, unspecified, acute embolism and thrombosis of right femoral vein cardiovascular and coagulations, unspecified, essential (primary) hypertension, major depressive disorder, single episode, unspecified, other chronic pain, unspecified. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R53 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Review of Section O (Special Treatments and Programs) indicated oxygen use. Review of the Physician's Orders revealed an order dated 3/27/2025 for oxygen at 2 L (liters) per minute via nasal cannula (NC) as needed for o2 sats oxygen in place for R53. Observation and interview during the initial screening on 3/25/2025 at 10:00 am revealed R53's O2 level was set at 3 LPM. R53 stated that it should be set at 2 LPM. Observation on 3/25/2025 at 03:28 pm revealed R53's O2 level remained set at 3 LPM. Observation on 3/26/2025 at 10:56 am revealed R53's O2 level was still set at 3 LPM. During an interview on 3/26/2025 at 3:52 pm with Licensed Practical Nurse (LPN) AA regarding R53's O2 setting, she stated that the order was for O2 to be set at 2 LPM. During an interview on 3/26/2025 at 5:40 pm with LPN BB, she confirmed that R53's O2 was set at 3 LPM. She went to the EMR and confirmed that the physician order was for O2 to be set at 2 LPM. During an interview on 3/27/2025 at 8:00 am with the Director of Nursing (DON), she revealed that she expected staff to follow and adhere to the physician order and to ensure that during rounds O2 was set at the ordered level. Based on observations, record review, resident and staff interviews, and review of the facility's policies titled, Admission/readmission Orders and Oxygen (O2) Therapy, the facility failed to transcribe and to have physician orders for catheter care for one of one resident (R) (R93) reviewed with an indwelling catheter; and failed to follow physician orders to administer O2 to one of 10 R's (R53) receiving O2 therapy. The deficient practice had the potential to cause risk of complications, urinary tract infections (UTI) and other catheter-related harm to R93, and low O2 levels to R53. Findings include: Review of the facility policy titled Oxygen Therapy dated January 2025 documented under Procedure: 1: Oxygen Therapy is to be provide under the direction of a written physician's order. A physician order for O2 therapy is to contain liter flow per minute via mask or canula/time frame. On an emergency basis, O2 may be used at 2L/minute (liters per minute-LPM) until the oxygen is ordered. Review of the facility policy titled Admission/readmission Orders revised February 2019 documented under Policy: Upon admission/readmission, orders for care of the resident are received from attending physician, placed on physician's order sheet and filed in the medical record. Under Procedure: . 2. re-admission to the facility after hospitalizations voids all previous orders. Therefore, all orders pertinent to resident must be re-written upon re-admission. 1. Review of the EMR revealed R93 was admitted to the facility with diagnoses including but not limited to obstructive and reflux uropathy and bladder-neck obstruction. Review of the 5 Day MDS assessment dated [DATE] documented in Section C (Cognition) a BIMS score of 8, which indicated R93 had moderately impaired cognition. Section H (Bowel and Bladder) Indwelling catheter and always incontinent. Section I (Active Diagnoses) Obstructive uropathy. Review of the Physician's Orders revealed no physician's orders for R93's foley catheter care. Review of the care plan dated 12/20/2024 documented including but not limited to: The resident has Indwelling Catheter, diagnosis (dx) of obstructive uropathy. The resident will be/remain free from catheter-related trauma through review date, The resident will show no signs and symptoms (s/sx) of Urinary infection through review date, Catheter: The resident has foley catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door; Monitor/document for pain/discomfort due to catheter; Monitor/record/report to MD (medical doctor) for s/sx UTI (urinary tract infection): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp; Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 3/25/2025 at 10:20 am revealed R93 in her room lying in bed. A foley catheter was observed on the side of the bed and the foley catheter bag was in a drainage bag holder. Observation on 3/26/2025 at 11:25 am revealed R93 in her room sitting up in bed. A foley catheter was observed on the side of the bed and the foley catheter bag was in a drainage bag holder. Observation on 3/27/2025 at 12:50 pm revealed R93 in her room sitting in a chair beside her bed eating lunch. R93 had a leg bag attached to the foley catheter. Review of the EMR for R93's After Visit Summary from [name of hospital] dated 12/10/2024 -12/18/2024 documented included but not limited to PLAN: Bladder outlet obstruction: continue foley catheter, F/U (follow up) with Urology. Interview on 3/25/2025 at 10:30 am with R93 revealed she stated she was admitted to the facility from the hospital with the foley catheter. Interview on 3/27/2025 at 10:55 am with Unit manager (UM) CC, she confirmed and verified there were no physician orders for R93's foley catheter care. She stated there was usually an admission and discharge nurse who would write the initial orders for the residents who were admitted , but she did not. She stated she would also review the admission information and write the orders. She stated she did not write the orders for the foley catheter for R93, and she should have checked to ensure the orders were there, but she did not. UM CC stated if there were no physician's orders, the outcome would be the staff may not be aware that R93 had a foley catheter. She stated the orders should be there in the EMR so that everybody would be aware that R93 had a foley catheter in place. She further stated the staff would not be able to sign off on the orders to show that catheter care was done. Interview on 3/27/2025 at 11:00 am with admission Nurse (AN) DD confirmed there were no physician orders for R93's foley catheter care. She stated she was familiar with R93, and she was aware she had a foley catheter. She stated she was responsible for writing the orders for the newly admitted residents and also for transcribing orders from the hospital notes. The AN stated she did not place the orders for R93's foley catheter in the EMR and she should have placed or transcribed the orders. She stated there should be orders for the foley catheter which included to be changed if needed, to notify the physician if there was leakage of the foley, and to empty the foley and document it. She stated an order should be there for the foley catheter and diagnosis to indicate the need for the foley catheter. She stated the outcome if there was no order for the foley catheter would be the staff would not know R93 had a foley catheter, they would not check it, and they would not change it if needed. AN DD stated the resident could be at risk for infection if catheter care was not done. Interview on 3/27/2025 at 11:31 am with the Director of Nursing (DON) revealed her expectations were for the nurses to ensure there were physician's orders and adhering to the physician's orders. She stated there should be physician's orders for the foley catheter and any licensed nurse was responsible for contacting the physician to put in the orders for the foley catheter or to transcribe the orders from the hospital discharge notes. The DON stated if there were no physician's orders, the outcome could be serious to the resident, such as obtaining a urinary tract infection or complications such as bleeding from the urinary tract.

Based on observations, interviews, record review, and review of the policies titled Self-Administration Protocol and Medication Administration: General Guidelines, the facility failed to assess one of four residents (R) (R80) for the ability to self-administer medications prior to leaving medications at the bedside. Findings included: A review of the policy titled Medication Administration: General Guidelines revealed the policy was: Procedure: 2. Medications are administered, in accordance with written orders of attending physicians, taking into consideration manufacturer's specifications and professional standards of practice. 3. Residents are allowed to self-administer medications when specifically authorized by the attending physician and the Interdisciplinary Team and in accordance with procedures for self-administration of medications. A review of the policy titled Self-Administration Protocol revealed the policy was: Procedure: 1. If the resident wishes to participate, the Interdisciplinary Team will complete the Medication Self-Administration Assessment. 2. A written order for the bedside storage of medication is placed in the resident's medical record. 3. Bedside storage of medications is indicated on the resident's medication administration record (MAR) for the appropriate medications. A review of the Quarterly Minimum Data Set (MDS) assessment date 9/6/2023 revealed that R80 presented with a Brief Interview for Mental Status (BIMS) score of 14, indication no cognitive impairment. A review of the care plan dated 2/11/2023 revealed there was not a focus area for the Self-Administration of medication, nor assessment indicating it was approved to leave medication at R80's bedside. A review of the physician's orders for the months of September 2023 and October 2023 revealed there was no order for the Self-Administration of medication. A review of the Medication Administration Record (MAR) for September and October 2023 revealed there was no order for Self-Administration of the medication Vitafusion Women's Gummy Vitamins to be left at R80's bedside. A review of the Educational In-Service Record dated 6/28/2023 through 6/29/2023 signed by Staff Development Coordinator revealed training for multiple topics including never leave medication in a resident's room unless ordered by the physician. An observation during medication administration pass with the Licensed Practical Nurse (LPN) GG on 10/25/2023 at 9:05 am revealed that R80 was taking her own medication at her bedside. The nurse stated that it was Vitafusion Women's Gummy Vitamins that she has been taking herself. When asked if she had an order to take it at her bedside, she said no. The resident stated that she has been taking vitamins for quite some time. Once the nurse returned to the cart and we looked through the MAR for a self-administration order for this medication it was determined that it was not found. An interview on 10/26/2023 at 11:10 am with the DON and Administrator revealed that R80's son was not aware that she had the vitamins and did not know where she had gotten them. The DON stated that the admission Nurse will be more observant of medication that the residents bring in and follow through with an order from the physician and follow the process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility documentation, the facility failed to maintain a clean, homelike environment as evidenced by dirty packaged terminal air conditioner (PTAC) filters and grills, detached PTAC cover, missing PTAC ventilation slats, a non-functioning bathroom emergency call light, a missing dresser drawer handle, a broken closet door handle, and detached baseboards which were observed on three of three units. Findings included: During an observation of resident rooms on 10/24/2023 revealed the following: * At 1:26 pm, room [ROOM NUMBER] was observed with dirty PTAC filters. * At 3:02 pm, room [ROOM NUMBER] was observed with dirty PTAC filters, and the bathroom emergency call light did not light up outside the room. * At 3:20 pm, room [ROOM NUMBER] was observed with dirty PTAC filters and a missing dresser drawer handle. During an observation of resident rooms on 10/25/2023 beginning at 11:35 am revealed the following: * room [ROOM NUMBER] was observed with dirty PTAC filters and grill. * room [ROOM NUMBER] was observed with dirty PTAC filters; bathroom emergency call light did not light up outside the room. * room [ROOM NUMBER]: PTAC filters were cleaned but the grill was still dirty and detached from the unit. * room [ROOM NUMBER]: PTAC filters were cleaned but the grill was still dirty; missing drawer handle from the dresser. * room [ROOM NUMBER] was observed with detached baseboards in the bathroom. * room [ROOM NUMBER] was observed with a clothes hanger holding closet door together. * room [ROOM NUMBER] was observed with peeling walls; worn/stained baseboards. A review of the electronic logbook documentation for heating, ventilation, and air conditioning (HVAC) units revealed the following steps: 1. Remove or open access cover. 2. Remove air filter and inspect for cleanliness. If the filter is dirty, either wash or replace depending on the type of filter. If clean, reinstall filter. 3. Re-install access cover. 4. Clean grill on cover. 5. Close and make sure it is secure. 6. At a minimum, air filters are to be replaced or thoroughly cleaned depending on the type of filter every three months. 7. Clean evaporator coils if lint buildup is present. 8. Inspect electrical motors and wires. A continued review of the electronic logbook documentation revealed air filters were cleaned or replaced on 8/4/2023 for half of the 200 hall and half of the 300 hall; on 9/29/2023 for half of the 300 hall and half of the 200 hall; and 10/17/2023 for the 100 hall. An observation on 10/24/2023 at 10:02 am in room [ROOM NUMBER] revealed shared bathroom base board unattached from the wall exposing caulking and sheetrock. An observation on 10/24/2023 at 10:11 am revealed room [ROOM NUMBER] had a trip hazard (loose baseboard) noted by the bathroom entrance. The Packaged Terminal Air Conditioner Unit (PTAC) was noted to be dusty and grimy. An observation on 10/24/2023 at 10:15 am and 10/25/2023 at 3:00 pm in room [ROOM NUMBER] revealed bed A headboard peeling exposing wooden bed frame material. Observation of closet doors in front of Bed A unattached and closet hinges missing screws unable to properly close. An observation of room [ROOM NUMBER] on 10/24/2023 at 10:20 am revealed the wall behind the head of the beds had peeling wall pieces with two openings in the wall. One opening measured approximately three inches tall by two inches wide and another measured one inch tall by two inches wide. An observation on 10/24/2023 at 10:21 am revealed the PTAC in room [ROOM NUMBER] had broken vents. There was wooden board noted behind the bed (320A) with scratched and missing paint. An observation on 10/24/2023 at 10:27 am revealed room [ROOM NUMBER] had wax build up on the floor in the bathroom. The PTAC was noted to be dusty and grimy with broken vents. An observation on 10/24/2023 at 10:37 am revealed room [ROOM NUMBER] PTAC was noted to be dusty and grimy. An observation of room [ROOM NUMBER] on 10/24/2023 at 1:29 pm revealed one PTAC located under the window had missing ventilation slats. Further observation revealed the PTAC had a large amount of fuzzy gray material in the fan filter. An observation of room [ROOM NUMBER] on 10/24/2023 at 1:30 pm revealed PTAC unit one located under the window had a large amount of fuzzy gray material with brown and white chunks of unknown substance in the fan filter. An observation on 10/25/2023 at 9:17 am revealed room [ROOM NUMBER] had a trip hazard (loose baseboard) noted by the bathroom entrance. The PTAC was noted to be dusty and grimy. An observation on 10/25/2023 at 9:21 am revealed that the PTAC in room [ROOM NUMBER] had broken vents. Behind bed A was a wooden board that was scratched up with missing paint. An observation on 10/25/2023 at 9:35 am revealed that room [ROOM NUMBER] had a wax buildup on the floor in the bathroom. The PTAC was noted to be dusty and grimy with broken vents. An observation on 10/25/2023 at 9:37 am revealed that the PTAC in room [ROOM NUMBER] was noted to be dusty and grimy. An observation tour on 10/26/2023 at 10:15 am with the Maintenance Director and the Executive Director verified room [ROOM NUMBER] with holes in the wall; room [ROOM NUMBER] PTAC unit with large amounts of gray, fuzzy matter and with clumps of brown and white chunks stuck in the fan filter; and room [ROOM NUMBER] PTAC unit with broken ventilation slats. During an interview on 10/26/2023 at 10:30 am with the Administrator, he stated that some PTAC units had been replaced recently but there was not a current order for PTAC units. He stated the normal delivery time for PTAC units was around three months. During an interview and walking rounds on 10/26/2023 at 10:40 am with the Administrator and Maintenance Director confirmed damaged closet doors, one peeled bed headboard, and one baseboard needing repair. During an interview with the President and [NAME] President of Operations on 10/26/2023 at 12:00 pm, the [NAME] President of Operations stated the Maintenance team does not have a policy for maintenance duties, but they do have a schedule and protocol for routine maintenance duties including the HVAC and PTAC units. He stated the PTAC filters should be inspected and cleaned at least every 90 days and have documentation to support the completion of those duties. When shown the pictures of one of the dirty filters, he confirmed the filters might need to be checked more frequently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of policy and procedures titled Comprehensive Person-Centered Care Plans the facility failed to implement a care plan for one of three residents (R) (R30) observed during wound care. Findings included: A review of the policy titled Comprehensive Person-Centered Care Plans dated March 2018, revealed each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Under the heading Procedure, number six revealed staff approaches are to be developed for each problem/strength/need and assigned disciplines will be identified to carry out the intervention. An observation of wound care for R30 with Registered Nurse (RN) AA and Certified Nursing Assistant (CNA) BB assisting RN AA was conducted on 10/25/2023 at 1:31 pm. Prior to beginning wound care, R30 voiced complaints of pain in her leg. RN AA acknowledged the resident stated she was hurting and continued with the wound care starting with the wound on R30's left lower extremity (LLE). During wound care R30 voiced pain in her leg as CNA BB positioned her left leg for the wound care. RN AA removed the dressing to R30's LLE. Each time CNA BB moved R30s leg during the dressing change R30 grimaced. A review of the electronic medical record (EMR) revealed R30 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses listed but not limited to infection of intervertebral disc (pyogenic) sacral /sacrococcygeal region, methicillin resistant staph infection cellulitis of left lower limb, and type 2 diabetes mellitus. A review of R30's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. A review of R30's care plan initiated on 7/20/2023 and last updated on 9/26/2023 indicated a problem of potential for skin breakdown/pressure ulcers and poor healing of wounds due to impaired mobility, DM2, and incontinence. The resident refuses to turn and reposition in spite of attempts. The resident refuses to get out of bed, refuses skin assessments, and is resistive to care. Care plan update on 5/5/2023: resident has a stage four pressure ulcer to sacrum. Care plan update on 9/26/2023: venous wound to left calf. The care plan goals included but were not limited to no new skin breakdown/pressure ulcers, area will remain free from signs/symptoms of infection, pressure ulcer will decrease in size. The care plan interventions included but were not limited to accept refusal of care and try later, pain evaluation prior to wound care, and medicate as ordered. A review of the EMR revealed physician's orders for R30 included but was not limited to cleanse wound to left calf with normal saline, pat dry. Apply collagen sheets, cover with ABD pad, wrap with kerlex, secure with tape, and cover with tubigrip three times a week and as needed. Sacrum wound care: Clean area with normal saline, pat dry then pack with iodoform gauze cover with island gauze with border dressing every Tuesday, Thursday, Sunday, and as needed. Pain medications ordered included: morphine sulfate 100 mg/5 mg, orally every six hours as needed, gabapentin 300 mg capsule, orally three times a day, diclofenac sodium one percent gel, apply four grams to upper extremities topically three time a day as needed, Aspirin enteric coated 81 milligrams (mg) orally daily, Acetaminophen 325 mg, two tablets orally every six hours as needed, and Percocet 7.5/325 mg one tablet orally every six hours as needed. A review of R30's Medication Administration Record (MAR) revealed medications that R30 had received on 10/25/2023 before 1:30 pm (prior to wound care) were gabapentin 300 mg, last dose administered on 10/25/2023 at 6:00 am and Percocet 7.5/325, last administered on 10/25/2023 at 9:09 am. During an interview with RN AA on 10/25/2023 at 1:31 pm, she acknowledged R30 complained of pain in her leg and stated she receives pain medication at scheduled times throughout the day. During an interview with RN AA on 10/26/23 10:07 am, RN AA revealed she confirmed and verified R30 does take Gabapentin 300 mg scheduled and on 10/25/2023 at 1:30 pm (at time wound care was performed) R30's last dose of Gabapentin was at 6:00 am. She reviewed R30's MAR and confirmed and verified she had received percocet at 9:09 am for complaints of pain. She confirmed and verified R30 had acetaminophen 325 mg, two tablets oral every six hours as needed, morphine sulfate 100 mg/5ml every six hours as needed, diclofenac sodium gel four grams topically upper extremities three times a day as needed ordered but none were given prior to wound care. She confirmed and verified R30 voiced her leg was hurting prior to wound care and during wound care, she verified and confirmed the resident was grimacing and complaining of pain when the CNA moved her left leg during wound care. She stated the process should be when a resident complains of pain, the wound care nurse lets the nurse assigned to the care of the resident know and determine if the resident can have any medication for pain. She stated R30 was a different breed and she is a little bit different. She clarified that statement with the statement of it is hard to tell if the resident is hurting because she yells and tells the nurse she is hurting when no one is touching her and if you touch her, she complains it is painful. She stated she should have gone to check with the nurse to see when she last had pain medication and when she could have pain medication but did not do this because R30 complains with pain upon light touch. During an interview with the Director of Nursing (DON) and the [NAME] President of Operations on 10/26/2023 at 10:16 am, the DON stated pain is what the resident states it is, the nurse should assess pain and treat, then reassess effectiveness of the treatment provided. She stated her expectation was for nursing to manage pain for patients who are in pain. During an interview with the Medical Director on 10/26/2023 at 2:19 pm, he stated that it is the expectation that the resident receives medications for pain as ordered and to receive pain medication before wound care procedures. He stated he just placed R30 on hospice to address her comfort needs and he expects that she be comfortable during any procedures and wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed provide daily oral care for two of three sampled residents (R) (R51 and R175). Findings included: A review of the undated facility policy titled, A.M. Care, revealed the following: Policy: A.M. Care will be given to residents daily. Responsibility: All Nursing Assistants Procedure: A. Oral Care: 1. Toothetts for people with no teeth 2. Brush teeth of residents with teeth A review of the undated facility policy titled, P.M. Care, revealed the following: Policy: P.M. Care is provided to the residents daily. Responsibility: All Nursing Assistants 1. An observation and interview with R51 on 10/24/2023 at 2:59 pm in her room, she was alert and oriented, dressed and groomed, and seated in her wheelchair. There was a foul odor coming from her mouth. She stated she was unsure about the frequency of her oral care stating she had very few teeth. She stated she rinses with mouthwash sometimes. A review of the Quarterly Minimum Data Set (MDS) assessment for R51, dated 8/6/2023, documented a Brief Interview for Mental Status (BIMS) score of 14, indicating little to know cognitive impairment. In addition, the assessment documented R51 as dependent for oral care, with helper performing all of the effort to complete the activity. A review of the care plan for R51 dated 4/25/2023 documented a risk for self-care deficit/impaired mobility with decline in function and mobility. Interventions included assisting with grooming, bathing, dressing, and meals as scheduled and as needed. An observation/interview with R51 on 10/25/2023 at 11:20 am in her room with family visitors. She was dressed and groomed, seated upright in her bed. She stated she had received a bed bath but no oral care. A family member asked R51 if she got oral care every day and she stated she did not. An observation and interview with R51 on 10/26/2023 at 11:10 am, she was alert and oriented, dressed and groomed, and seated in her wheelchair. She stated she had not received oral care today. 2. During an observation and interview with R175 on 10/24/2023 at 3:05 pm in her room, she was alert and oriented, dress and groomed, and seated in her wheelchair. She stated she did not receive oral care today. A review of the admission MDS assessment was not completed for R175. R175 was admitted to the facility on [DATE]. A review of the baseline care plan for R175, dated 10/12/2023, did not address oral care. During an observation and interview with R175 on 10/25/2023 at 1:42 pm, she was dressed and groomed but stated she did not receive oral care today. In addition, she stated she could brush her own teeth but would need to have everything set up for her on her bedside table. During an observation and interview with R175 on 10/26/2023 at 11:05 am, she was dressed and groomed and seated upright in her bed. She stated she did not receive oral care this morning. During an interview with Certified Nursing Assistant (CNA) NN on 10/26/2023 at 11:20 am, she stated it was her first day working at the facility. She stated residents should receive oral care daily. During an interview with CNA OO on 10/26/2023 at 11:25 am, she stated residents should receive oral care twice a day. During an interview with CNA PP on 10/26/2023 at 1:03 pm, she stated she bathed both R51 and R175 today, but she did not perform oral care; she left that to another CNA for later today because she stated the residents often like to sleep late. When asked why she did not perform the oral care for R51 and set up R175 to perform her own oral care, she did not explain any further. She repeated that she left those tasks for other CNAs to perform. She stated she did not take care of R51 and R175 on 10/24/2023 and 10/25/2023 because she was not working on those days. During an interview with the Director of Nursing (DON) on 10/26/2023 at 3:21 pm, she stated residents should receive oral care once a shift, at least two times a day. She could not determine why R51 and R175 did not receive oral care on 10/24/2023 and 10/25/2023 along with their baths in the morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of policy and procedures titled Pain Evaluation/Management the facility failed to provide pain management for one of three residents (R) (R30) observed receiving wound care. Findings included: A review of policy titled Pain Evaluation / Management dated April 2014, revealed the policy of the facility for all residents be evaluated for pain at time of admission, re-admission, and as needed. If a new episode of pain is noted complete a Pain Management Evaluation, implement non-pharmacological interventions as appropriate, notify (physician) of unrelieved pain. The (Physician) is called after completion of the Pain Management Evaluation Tool to review evaluation and develop further interventions for relief of pain. An observation of wound care for R30 with Registered Nurse (RN) AA and Certified Nursing Assistant (CNA) BB assisting the nurse was conducted on 10/25/2023 at 1:31 pm. CNA BB and RN AA performed hand hygiene prior to entering room and donned gloves. RN AA explained the procedure to the resident. Resident voiced her leg was hurting. RN AA acknowledged the resident stated her leg was hurting. RN AA cleaned the bedside table and placed a barrier for supplies after the table had dried (four minutes later). RN AA removed gloves, performed hand hygiene, and donned new gloves. CNA BB provided privacy for R30 then she positioned the residents Left Lower Extremity (LLE) for the dressing change. R30 again voiced pain, and grimaced as CNA BB positioned her left leg. CNA BB then held her leg steady, and the resident calmed down. Each time CNA BB moved R30's leg R30 grimaced. The RN AA removed old dressing to Left Lower Extremity (LLE) and discarded the dressing in trash bag, removed gloves, performed hand hygiene, donned clean gloves. RN AA cleansed the wound with a 4x4 gauze soaked in normal saline, patted wound dry with clean 4x4s. Removed her gloves, performed hand hygiene, donned clean gloves. RN AA applied collagen to wound bed covered with an ABD pad, wrapped with kerlix, and placed tubi grip over the dressing. RN AA removed trash bag then removed gloves, performed hand hygiene, donned clean gloves. RN AA opened a clean trash bag and placed it within her reach. CNA BB removed her gloves, performed hand hygiene, and donned clean gloves. CNA BB repositioned R30, with RN AA's assistance, onto her right side to expose the wound on her sacrum. RN AA removed her gloves, performed hand hygiene, and donned clean gloves. RN AA removed sacral dressing and discarded it in the trash bag. RN AA removed gloves, performed hand hygiene, and donned clean gloves. RN AA cleaned the wound with 4x4 gauze soaked in normal saline. RN AA removed her gloves, performed hand hygiene, and donned clean gloves. RN AA packed wound with iodoform gauze and covered wound with sacral island gauze with border dressing. RN AA removed her gloves, performed hand hygiene, and donned clean gloves. RN AA and CNA BB repositioned R30 to offload pressure to the left side of body. Both the RN AA and CNA BB gathered trash, removed gloves, performed hand hygiene prior to leaving room and trash was taken out as they left room. A review of the electronic medical record (EMR) revealed R30 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses listed but not limited to infection of intervertebral disc (pyogenic) sacral /sacrococcygeal region, methicillin resistant staph infection cellulitis of left lower limb, and Diabetes Mellitus 2 (DM 2). A review of R30's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. A review of R30's care plan initiated on 7/20/2023 and last updated on 9/26/2023 indicated a problem of potential for skin breakdown/pressure ulcers and poor healing of wounds due to impaired mobility, DM 2, and incontinence. R30 refuses to turn and reposition in spite of attempts. She refuses to get out of bed, refuses skin assessments, and is resistive to care. Care plan update on 5/5/2023 revealed R30 has a stage four pressure ulcer to sacrum. Care plan update on 9/26/2023 revealed R30 had a venous wound to left calf. The care plan goals included but were not limited to no skin breakdown/pressure ulcers, the area will remain free from signs/symptoms of infection, the pressure ulcer will decrease in size. Interventions included but not limited to accept refusal of care and try later, pain evaluation prior to wound care, medicate as ordered, Registered Dietitian to make recommendations as needed, assess skin daily during care and as scheduled and report any bruises, assist with turning and repositioning every two hours and as needed while in bed. A review of the EMR revealed physician's orders for R30 included but was not limited to cleanse wound to left calf with normal saline, pat dry. Apply collagen sheets, cover with ABD pad, wrap with kerlex, secure with tape and cover with tubigrip three times a week and as needed. Sacrum: Clean area with normal saline, pat dry then pack with iodoform gauze cover with island gauze with border dressing every Tuesday, Thursday, Sunday, and as needed. Pain medications ordered included: morphine sulfate 100 mg/5 mg, orally every six hours as needed, gabapentin 300 mg capsule, orally three times a day, diclofenac sodium one percent gel, apply topically four grams to upper extremities three time a day as needed, Aspirin enteric coated 81 mg daily, Acetaminophen 325 mg, two tablets orally every six hours as needed, and Percocet 7.5/325 mg, one tablet orally every six hours as needed. A review of R30's Medication Administration Record (MAR) revealed medications that R30 had received on 10/25/2023 before 1:30 pm (prior to wound care) were gabapentin 300 mg (milligrams), last administered on 10/25/2023 at 6:00 am and Percocet 7.5/325, last administered on 10/25/2023 at 9:09 am. During an interview with RN AA on 10/25/2023 at 1:31 pm, she acknowledged R30 complained of pain in her leg and stated she receives pain medication at scheduled times throughout the day. An interview with RN AA on 10/26/2023 at 10:07 am revealed she confirmed and verified R30 does take Gabapentin 300 mg scheduled and on 10/25/2023 at 1:30 pm (at time wound care was performed) R30's last dose of Gabapentin was at 6:00 am. She reviewed R30's MAR and confirmed and verified she had received Percocet at 9:09 am for complaints of pain. She confirmed and verified R30 had Acetaminophen 325 mg, two tablets every six hours as needed, morphine sulfate 100 mg/5ml every six hours as needed, diclofenac sodium gel four grams topically to upper extremities three times a day as needed ordered but none were given prior to wound care. She confirmed and verified R30 voiced her leg was hurting prior to wound care and during wound care, she verified and confirmed the R30 was grimacing and complaining of pain when the CNA positioned her left leg during wound care. She stated the process should be when a resident complains of pain, the wound care nurse lets the nurse assigned to the care of the resident know and determine if the resident can have any medication for pain. She stated R30 was a different breed and she is a little bit different. She clarified that statement with the statement of it is hard to tell if the resident is hurting because she yells and tells the nurse she is hurting when no one is touching her and if you touch her, she complains it is painful. She stated she should have gone to check with the nurse to see when she last had pain medication and when she could have pain medication but did not do this because R30 complains with pain upon light touch. During an interview with the DON and the [NAME] President of Operations on 10/26/2023 at 10:16 am, the DON stated pain is what the resident states it is, the nurse should assess pain and treat, then reassess effectiveness of treatment. She stated her expectation was for nursing to manage pain for patients who are in pain. During an interview with the Medical Director on 10/26/2023 at 2:19 pm, he stated that his expectation is that the resident receives medications for pain as ordered and to receive pain medication before wound care procedures. He stated he just placed R30 on hospice to address her comfort needs and he expects that she be comfortable during any procedures and wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of policy and procedures titled Handwashing, Pressure Ulcer/Injury and Skin Conditions Guide for Wound Evaluation Documentation and Treatment Technique Competency Audit, the facility failed to ensure hand hygiene was completed between glove changes and between removing old dressings and application of clean dressing during wound care for two of three resident (R) (R50 and R15) reviewed for wound care. Findings included: A review of the policy titled Handwashing dated September 2019, revealed the policy was staff will use proper hand washing technique to prevent the spread of infection. A review of the policy titled Pressure Ulcer/Injury & Skin Conditions Guide for Wound Evaluation Documentation dated November 2017, revealed the practice of the facility was to ensure residents with pressure ulcers receive necessary evaluation and treatment to promote healing, prevent infection, and prevent new ulcers from developing. A review of Treatment Technique Competency Audit dated November 2017, revealed steps taken during wound care. Step number seven described cleaning of wounds, Step number eight was - remove gloves, wash hands, and re-glove. Steps nine through ten were apply medication as ordered using clean technique and apply a dated cover dressing. 1. An observation of wound care was conducted on 10/25/2023 at 10:20 am for R50 with Registered Nurse (RN) AA (wound care nurse) and Certified Nursing Assistant (CNA) BB. Observed the RN AA explain to R50 the wound care procedure and ask permission for surveyor to observe. RN AA cleaned bedside table and set up supplies for dressing change. RN AA performed hand hygiene and donned clean gloves, she then assisted by CNA BB repositioned R50 for wound care to sacrum. RN AA removed gloves, performed hand hygiene, and donned clean gloves. RN AA removed dressing from sacral wound and discarded into trash receptacle, she then removed gloves performed, hand hygiene, donned clean gloves. RN AA using a 4x4 soaked with half strength Dakin's cleansed the wound then with a syringe flushed the wound with half strength Dakin's. RN AA removed gloves and donned clean gloves (she did not perform hand hygiene between removal and donning of gloves). RN AA packed the wound with one inch strip of iodoform packing, placed calcium alginate in wound bed covered with an Abd pad, then covered with a bordered sacrum dressing. RN AA applied zinc oxide to right buttocks. RN AA removed gloves, performed hand hygiene, donned clean gloves, then assisted the CNA BB with positioning resident in a comfortable position. RN AA removed trash from the room. A review of the electronic medical record (EMR) revealed R50 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses listed but not limited to neuropathy, radiculopathy thoracic region, radiculopathy lumbar region, and diabetes mellitus type 2 (DM 2). A review of physician orders and Treatment Administration Record (TAR) revealed orders for wound care as: clean with half strength Dakin's solution then crush and sprinkle metronidazole 500 mg (milligram) tablet (three tab) to wound bed, then pack Dakin's half strength gauze, ABD pad, superabsorbent gelling fiber pad, superabsorbent gelling fiber with silicone sacrum. Peri wound apply antifungal OTC cream/powder and zinc ointment daily. A review of Wound Care Physician Note dated 10/19/2023 revealed new orders were written as discontinue alginate calcium, super absorbent gelling fiber pad, super absorbent gelling fiber with silicone border and faced, anti-fungal OTC. New orders included primary dressing alginate calcium with silver, pack wound, continue to flush wound with half strength Dakin's, secondary dressing continue ABD pad and add gauze island with boarder. Peri wound - continue zinc ointment. A review of R50's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicates R50 was cognitively intact. Section H (Bowel & Bladder) revealed R50 was always incontinent of bladder and bowel. Section M (Skin Conditions) revealed there was one stage two pressure ulcer present upon admission and was present at time of assessment. A review of R50's care plan dated 8/18/2023 indicated a problem of impaired skin integrity risk for further skin breakdown, poor wound healing related to impaired mobility self-care deficit, incontinence, resident has a stage two pressure ulcer to sacrum (care plan updated resident had stage two on admission to the left buttocks not sacrum resolved on 8/12/2023. On 9/1/2023 a sacrum with stage one, on 9/7/2023 a sacrum unstageable, on 9/16/2023 sacrum stage four. Goals included but not limited to wounds will heal with no signs or symptoms of infection noted. Interventions included but not limited to skin assessments as ordered and daily during care report any red bruised or broken skin treatments as ordered monitor effectiveness of treatments and status of wound as scheduled monitor nutrition and assist with meals as needed assist with turning and repositioning as needed and requested providing continuance care as needed use moisture barrier cream, use pressure redistribution and mattress and a pressure relieving device for wheelchair. During an interview with RN AA on 10/25/2023 at 11:00 am, she stated she always washes her hands but stated she was nervous and must have forgotten to sanitize her hands between glove change after cleansing the wound and putting new dressing on wound. She revealed there is another wound care nurse who shares responsibilities with her regarding orders entered into the computer timely, but she is on medical leave, therefore she (RN AA) is behind in putting orders into the computer. She stated the physician visits every Thursday and she followed his new orders written on 10/19/2023. 2. An observation of wound care was conducted for R25 on 10/25/2023 at 10:43 am with RN AA (wound care nurse) and CNA BB. RN AA entered the room and explained to R15 the wound care procedure and asked permission for the surveyor to observe. RN AA provided privacy, then performed hand hygiene and donned a clean pair of gloves. RN AA cleansed table to set supplies upon, removed gloves performed hand hygiene and obtained supplies needed for dressing change. Upon returning to the room, she performed hand hygiene, placed a barrier on clean table and set up supplies on the table. RN AA removed her gloves, performed hand hygiene, and donned clean gloves. CNA BB positioned the resident for wound care, removed disposable incontinence garment and exposed sacral wound with no dressing on wound. RN AA performed hand hygiene and donned clean gloves, then cleansed the wound with soaked 4x4 (nurse stated she was using saline and Dakin's solution) she discarded the 4x4 in trash receptacle. RN AA did not remove her gloves/perform hand hygiene/don clean gloves. Rn AA applied Santyl ointment to a clean 4x4 and placed the 4x4 with the ointment to the wound bed inside the wound and covered the wound with a bordered sacral gauze. RN AA removed gloves, placed them in trash receptacle, and performed her hand hygiene. She then removed the trash from the room. A review of EMR for R15 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of but not limited to DM2 with diabetic polyneuropathy, pressure ulcer of sacral region stage four, hyperlipidemia, and anemia. A review of R15's Quarterly MDS assessment dated [DATE] revealed a BIMS of seven, which indicated severe cognitive impairment. A review of care plan revealed problem onset of 8/12/2023 for potential for further skin breakdown and poor healing of wounds due to sacral wound, impaired mobility, poor intake at meals, and self-care deficit and episodes of incontinence of bladder and bowel. The resident is non-compliant with turning and repositioning as needed. The resident likes to stay in the same place in bed. A Stage four pressure wound to coccyx area. Goals included but not limited to pain will be managed, no increased complaints of pain or non-verbal indicators of pain; no further skin breakdowns/pressure ulcers will present, area will be free of infection, area will decrease in size and width over the next review. A review of physician orders revealed orders listed but not limited to lidocaine five percent ointment, apply to coccyx wound bed once daily with each dressing change and as needed; coccyx - clean with normal saline, pat dry, then Santyl ointment to wound bed, cover with gauze island dressing with border, peri wound - zinc ointment every day and as needed. A review of physician note dated 10/12/2023 revealed dressing treatment plan as primary dressing Santyl, secondary dressing - gauze island with border peri wound - zinc ointment. An interview with RN AA on 10/25/2023 at 11:00 am revealed the resident is non-compliant and most days she finds that he removes his dressing from the previous day. She stated she always washes her hands but was nervous and must have forgotten to change gloves after cleaning the wound and prior to placing new dressing on wound. An interview with the Director of Nursing (DON) on 10/26/2023 at 11:15 am revealed that her expectation was for staff to reduce the risk of infection by utilizing hand hygiene during wound care. She stated staff should use good hand hygiene after cleaning wounds and prior to applying new dressing to a wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an emergency bathroom resident call light as evidenced by a malfunctioning emergency call light in one of 24 sampled bathrooms rooms (room [ROOM NUMBER]). Findings included: During an observation of resident room [ROOM NUMBER] on 10/24/2023 at 3:02 pm and 10/25/2023 at 11:35 am revealed the bathroom emergency call light did not light up outside the room when engaged. During an interview and walking rounds on 10/26/2023 at 10:40 am with the Administrator and Maintenance Director confirmed the malfunctioning call light. The Administrator asked the Maintenance Director to immediately replace the light bulb, which did not correct the problem. The Maintenance Director contacted a repairman to repair or replace the call light. On 10/26/2023 at approximately 2:00 pm, the repairman was observed replacing the bathroom emergency call system in room [ROOM NUMBER].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, the facility failed to develop a person-centered care plan for one resident (R) R#5 for the use of an indwelling urinary catheter. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, there are seven residents with indwelling or external catheters. Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans dated 3/2018 revealed the policy as each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Procedure 5. For each problem, need, or strength a resident-centered goal is developed. Goals should be measurable. 6. Staff approaches are to be developed for each problem/strength/need with disciplines identified to carry out interventions. 9. Upon a change in condition, the comprehensive person-centered care plan will be updated if applicable. Review of medical record for R#5 revealed resident was admitted to the facility on [DATE]. Diagnoses include but are not limited to the type 2 diabetes, stage 3 pressure ulcer of sacrum and right buttock, anemia, major depressive disorder, insomnia, urinary tract infection (UTI), benign prostatic hyperplasia (BPH), and anxiety disorder. The resident's most recent Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicates no cognitive impairment. Section G revealed resident requires extensive assistance of two people with bed mobility, transfers, dressing, toileting, and personal hygiene. Section H reveals resident is occasionally incontinent with no evidence that resident has indwelling urinary catheter. Review of the care plan for R#5, dated 2/15/2022, revealed resident has increased risk for urinary tract infection due to incontinence, impaired mobility, and self-care deficit. There is no evidence that resident had indwelling urinary catheter. Review of the February 2002 Physician's Order (PO) revealed that there was a PO dated 2/16/2022 for the indwelling catheter to drain to bedside bag and to leave catheter in place until Urology consult. Review of nurses note dated 2/12/2022 at 3:16 a.m. revealed resident was sent to the emergency room post fall and was admitted with abdominal distention. Resident was referred to urology for Foley catheter insertion. Resident is to follow-up with urology after discharge from the hospital and continue Foley catheter upon discharge back to the facility. Foley catheter is to stay in place until follow-up appointment with urologist. Resident was educated that he was discharged with orders to keep Foley in place until his appointment with urologist and he verbalized understanding. Observation 2/16/2022 at 9:11 a.m. urinary catheter intact with bright yellow urine flowing into the bedside drainage bag. Catheter tubing secured to the right thigh with a device to facilitate unobstructed urine flow. Interview on 2/16/2022 at 9:35 a.m. with R#5, stated he was told in the hospital that he had a urinary infection and he had to come back to the nursing home with the Foley catheter in place until he goes to see another doctor. Interview on 2/16/2022 at 12:35 p.m. with Licensed Practical Nurse/Minimum Data Set (LPN/MDS) Assistant BB, stated R#5 does not have a Foley catheter, he uses a urinal. She was asked to review current PO's and nurses note and stated she wasn't aware of the catheter. She verified that R#5 was not care planned for urinary catheter use in the electronic medical record (EMR) or paper chart. During continued interview, LPN/MDS Assistant AA stated she was new to the position and that she was the one who had not created the care plan for R#5 for indwelling catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interviews, the facility failed to ensure that psychotropic medications including antianxiety medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) R#84 reviewed for unnecessary medications. Findings includes: Review of the facility policy titled Behavior Management and Psychopharmacological Medication Monitoring Protocol, revised September 2003 revealed the policy statement as residents who receive antipsychotic, antidepressant, sedative/hypnotic, or anti-anxiety medications are to be maintained at the safest, lowest dosage necessary to manage the residents' conditions. Procedure 3. PRN psychotropic drugs should be limited to 14 days unless the primary physician has documentation supporting the rational in the medical record and has indicated the duration for the PRN order. Review of medical record for R#84 revealed resident was admitted to the facility on [DATE]. Diagnoses include but are not limited to chronic diastolic heart failure, anemia, diabetes, hypertension (HTN), depression, and anxiety. The resident's most recent Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 7, which indicates severe cognitive impairment. Section G revealed resident requires limited assistance of one person with bed mobility, dressing, toileting, and extensive assistance with personal hygiene. Section N revealed resident received antianxiety and antidepressant medications seven of seven days. Review of the physician orders for R#84 for February 2022 revealed the following medications: Celexa 20 milligrams (mg) by mouth daily for depression, Bupropion HCL SR 150 mg by mouth two times daily for depression and Xanax 0.25 mg by mouth two times daily as needed with an original order date of 1/3/2022. There is no evidence of a 14 day stop date or a rationale from the physician for the extension past 14 days. Interview on 2/17/2022 at 9:55 a.m. with the Director of Nursing (DON) stated that R#84 was readmitted from the hospital with the Xanax order. She verified there is not a 14 day stop order for the Xanax, or an order to continue the Xanax past the 14 days. During further interview, she verified there was no documentation from the physician with a duration, extension, or reason for continuation of the order on the record. Interview on 2/17/2022 at 1:10 p.m. with Nurse Practitioner (NP) EE verified that she has not addressed the continuation of the PRN Xanax which was ordered on 1/3/2022.