**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview the facility failed to revise the Care Plan to reflect the use of Paid Nutritional Assistants (PNAs) for 1 of 1 resident reviewed for meal assistance (Resident #24). The facility reported a census of 31 residents. Findings include: Resident #24 Minimum Data Set (MDS) assessment dated [DATE] documented Resident #24 with severely impaired decision making and a long/short term memory problem. Resident #24 exhibited inattention (difficulty in ability to focus; easily distracted) and disorganized thinking (rambling/irrelevant conversations) which were continuously present. The MDS further documented Resident #24 was dependent upon staff for eating (bringing food/fluids to the mouth), but did not exhibit any swallowing difficulties. The MDS detailed Resident #24 with diagnoses of stroke, anxiety, and Alzheimer's Disease. A Physician Order Sheet signed by the Provide on 3/07/25 showed an order for a pureed diet as of 3/03/25. Resident #24 Care Plan directed she needed a general, pureed diet with thin liquids and could become restless at meals and turn her head away when eating. The Care Plan directed the aides to feed her all of her meals with a goal to be comfortable eating without coughing or choking. The Care Plan further directed Resident #24 required the assistance of one person for assistance with eating, but did not define if that could be a PNA. Interview on 4/01/25 at 1:22 PM the DON voiced she was not aware of the need to Care Plan if a resident could be safely assisted by a PNA. On 4/01/25 at 1:55 PM Staff D, Licensed Practical Nurse (LPN) provided a list dated 3/10/25 which read these staff are certified to feed resident's if needed and short staffed: Staff A Activity Assistant, Staff E Activity Coordinator, Staff G PNA, Staff H Cook/Dietary Aide, Staff J Social Services, and Staff F, I, and K Environmental Services. The 3/10/25 list did not entail any actual resident names these staff could assist or reference to see the resident Care Plans. During an interview on 4/01/25 at 2:04 PM Staff L, RN, Case Manager, reviewed Resident #24 Care Plan and reported the Care Plan references the resident needed a one assist for eating. The Care Plan did not address if the one person assist needed to be a Certified Nursing Assistant or PNA. Staff L voiced she was not aware resident Care Plans needed to address if a PNA could assist a resident with their meals, so there would be no documentation of PNAs on any of the resident Care Plans. On 4/01/25 at 2:05 PM the DON reported she had not been aware of the requirement for the PNA use to be reflected in the Care Plan and the would start going forward. On 4/03/25 at 10:15 AM the facility provided a list of seven residents requiring assistance with meals. During an interview on 4/03/25 at 10:40 AM the DON reported she would expect the Care Plans to be updated to include if a PNA could safely assist a resident with eating and she expected resident Care Plans to be revised when needed. She stated the facility did not have a policy on revising the Care Plan but would writing a policy soon.

Based on observation, record review, staff interview, and policy review the facility failed to track prophylactic antibiotics (ATB) for 1 of 1 residents reviewed (Resident #12). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) for Resident #12 dated 1/8/25 documented had diagnoses of hemiplegia, depression, and anxiety. The MDS also documented that she takes an ATB daily. During an observation of Resident #12 current Medication Administration Record (MAR) on 4/1/25 at 10:07 AM revealed she had been on Doxycycline 100 milligrams (mg), daily, since 9/28/24 for keratitis (an inflammation of the cornea, the clear, dome-shaped front window of the eye) and Erythromycin eye ointment, twice a day, since 9/27/24 for keratoconjunctivitis (inflammation of both the cornea (keratitis) and conjunctiva (conjunctivitis), the clear tissues covering the surface of the eye, often causing symptoms like redness, pain, and blurry vision) of left eye. Record review of Resident #12 Ophthalmology visit note on 9/27/2024 gave orders for Erythromycin (ATB) ointment to both eyes twice daily and Doxycycline (ATB) 100 mg daily. Record review of Resident #12 Ophthalmology visit note on 3/20/2025 documented she has a history of superficial keratitis in both eyes, and continues to use Doxycycline 100 mg daily and Erythromycin ointment twice a day to both eyes. During an observation on 4/2/25 at 1:19 PM of the facilities Infection Control Logs for the months of January, February, and March 2025 lacked tracking of Resident #12 ATB's (Erythromycin and Doxycycline). During an interview on 4/2/25 at 1:19 PM with the Infection Preventionist (IP) revealed she does not track Resident #12 ATB on the facilities Infection Control Logs as they are prophylactic ATB. Record review of Resident #12 Pharmacy Review Logs for 2024 lacked documentation her ATB's were reviewed during the routine monthly pharmacist reviews. During an interview and observation on 4/3/25 at 9:38 AM with the Infection Preventionist revealed she has updated the Infection Control Logs for January, February, and March 2025 and they now include all prophylactic ATB. She revealed they were not on there on 4/2/25 at 1:19 PM during initial review. During an interview and observation on 4/3/25 at 10:19 AM the Infection Preventionist provided an undated form, Total Number of Infections 1st Quarter 2025, she revealed she updated the form today on 4/3/25 to include the total number of prophylactic ATB's to review to Quality Assurance (QA) and informed it did not have prophylactic ATB's on it till now. During an interview 4/3/25 at 10:43 AM with the Director of Nursing (DON) revealed she would expect all prophylactic ATB to be tracked on the monthly Infection Control log. She revealed she was informed on 4/2/25 they were not being tracked. Record review of the facilities Antibiotic Stewardship Policy, dated 2/2024 lacked instruction to monitor for prophylactic antibiotics. The policy instructed the Pharmacy Consultant to review the antibiotic use for each resident during the Medication Regimen Review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, document review, and staff interview the facility failed to safely utilize Paid Nutritional Assistants (PNA's used interchangeably with Paid Feeding Assistant (PFA) based on resident assessment and Care Plan for 1 of 1 residents sampled (Resident #24). The facility identified a census of 31 residents. Findings include: Resident #24 Minimum Data Set (MDS) assessment dated [DATE] documented Resident #24 with severely impaired decision making and a long/short term memory problem. Resident #24 exhibited inattention (difficulty in ability to focus; easily distracted) and disorganized thinking (rambling/irrelevant conversations) which were continuously present. The MDS further documented Resident #24 was dependent upon staff for eating (bringing food/fluids to the mouth), but did not exhibit any swallowing difficulties. The MDS detailed Resident #24 with diagnoses of stroke, anxiety and Alzheimer's Disease. A Physician Order Sheet signed by the Provide on 3/07/25 showed an order for a pureed diet as of 3/03/25. Resident #24 Care Plan directed she needed a general, pureed diet with thin liquids and could become restless at meals and turn her head away when eating. The Care Plan directed the aides to feed her all of her meals with a goal to be comfortable eating without coughing or choking. The Care Plan further directed Resident #24 required the assistance of one person for assistance in eating, but did not define if that could be a PNA. Resident #24 Care Plan also directed to observe her for seizure activity. Observation on 3/31/25 at 11:45 AM revealed Staff A, PNA assisting Resident #24 with her pureed lunch from a divided plate. Resident #24 did not exhibit coughing or choking at this time. Observation on 4/01/25 at 7:45 AM revealed Staff A, PNA assisting Resident #24 with her pureed breakfast meal. Resident #24 did not exhibit coughing or choking at this time. During an interview on 4/01/25 at 9:02 AM Staff A reported to her knowledge Resident #24 did not cough or choke with her meals. She reported she wasn't aware of any list or guidance from nursing that detailed what residents she could assist for meals. She reported she had just been told she couldn't feed Resident #4 because she does have swallowing and choking problems. She reported it was the Director of Nursing (DON) that had told her she could not assist Resident #4. Staff A further voiced she wasn't sure who actually supervised the PNA's, but she would probably report to the Director of Nursing (DON) if she had any concerns on a resident. On 4/01/25 at 1:15 PM Staff B, Registered Nurse (RN) reported she didn't think Resident #24 had any choking or swallowing issues. She was not sure who supervised the PNA's. She did not do any resident assessment regarding meal assistance. Interview on 4/01/25 at 1:22 PM the DON reported she was not sure if there was an assessment in the resident charts or any type of assessment to address which residents the PNA's could safely assist. She reported she would need to check with Staff C, RN. The DON voiced she was not aware there needed to be an assessment or of the need to care plan if a resident could be safely assisted by a PNA. On 4/01/25 at 1:55 PM Staff D, Licensed Practical Nurse (LPN) reported she is a travel nurse and she had not been necessarily trained on which resident's the PNA's could assist, but they have an assistive table and the resident's that require assistance and supervision sit at that table. Staff D stated there is a Certified Nursing Assistant (CNA) that sits at the table that can watch the PNA's. They were provided with a list of the staff that could assist resident's with meals. Staff D provided a list dated 3/10/25 which read these staff are certified to feed resident's if needed and short staffed: Staff A Activity Assistant, Staff E Activity Coordinator, Staff G PNA, Staff H Cook/Dietary Aide, Staff J Social Services, and Staff F, I, and K Environmental Services. During an interview on 4/01/25 at 2:04 PM Staff L, RN, Case Manager, reported she was not aware there needed to be an assessment or the use of PNA's needed to be addressed in the resident's care plan. Staff L further stated she wasn't aware so there would be no documentation of an assessment and no documentation of PNA use on any of the resident Care Plans. On 4/01/25 at 2:05 PM the DON reported she had not been aware of the requirement for an assessment or for the PNA use to be reflected in the Care Plan and the would start going forward. Interview on 4/01/25 at 2:14 PM the Consulting Dietician reported she had not had to review any residents for choking since she started with the facility in January 2025. On 4/03/25 at 10:15 AM the facility provided a list documenting seven residents in the facility that required staff to assist with meal assistance. The Paid Feeding Assistant (PFA) Policy revised 1/2017 provided by the facility directed the following: 1. The PFA will be under the supervision of a registered nurse or licensed practical nurse. The nurse may not be in visual contact with the PFA but within close proximity to the dining room. 2. In an emergency the PFA must call for a supervisory nurse by voice, the resident call system or the facility paging system. 3. The RN/LPN will assign the PFA to a resident who do not have complicated feeding problems. Complicated feeding problems include, but are not limited to difficulty swallowing, recurrent lung aspirations and tube, parenteral and intravenous feedings. Resident selection will be based on the charge nurse assessment, resident's last assessment and plan of care.

Based on observation, policy review, document review, consulting dietician and staff interviews, the facility failed to serve approved menu substitutions of similar nutritional content. The facility identified a census of 31 residents. Findings include: On 3/31/25 (Monday) the Certified Dietary Manager (CDM) provided a copy of the Week 4 Tuesday Menu which included to provide a Mandarin spinach salad at the noon meal. The Week 4 Tuesday Noon menu lacked documentation of the substitution and reason why the substitution was needed on the actual menu. The CDM reported they had tried to serve the Mandarin spinach salad a few times and it didn't go over well. She stated she would be substituting a seven-layer salad in its place. During an interview on 4/01/25 at 11:09 AM the CDM reported the seven-layer salad contained cucumbers, bacon, cheese, peas, eggs, lettuce, and a sugar mayonnaise dressing. Observation on 4/01/25 from 11:20 AM to 11:50 AM revealed the CDM served 19 resident the seven-layer salad. During an interview on 4/01/25 at 2:17 PM the Consulting Dietician reported she had not approved any substitutions for the Week Four Tuesday Noon Menu. She stated the seven-layer salad would not be an appropriate substitution for the Mandarin spinach salad. The menu substitution would need to be a similar option with similar nutritional content. The seven-layer salad and the Mandarin spinach salad were not the same nutritional content. On 4/02/25 at approximately 8:35 AM the CDM provided the Seven-Layer Lettuce Salad recipe which included: a. 4 cups chopped celery b. 1 cup onion c. 6 cups frozen peas d. 4 chopped cucumbers e. 6 cups chopped bacon f. 2 dozen chopped eggs g. 4 cups shredded cheese h. 5 cups salad dressing i. 1/2 sugar The Seven-Layer Lettuce Salad recipe contained no nutrient analysis (calories, carbohydrate, protein, fat, sodium, or micronutrient breakdown). On 4/02/25 at 8:35 AM the CDM provided a small tablet of hand-written menu substitutions. The tablet documented on 4/1/25 the seven-layer salad in place of the spinach salad. The untitled tablet noted ten hand written substitution entries from 1/23 (no year) to April 1 (no year). None of the substitution entries had been signed off as approved by the Dietician. On 4/02/25 at 9:05 AM the CDM reported they had just changed Dietician's two months ago and the prior Dietician did not require her to notify her of substitutions and didn't require anything to be sign off on menu substitutions. On 4/02/25 at 9:00 AM the CDM provided the following: a. Mandarin Spinach Salad with Poppy seed dressing recipe (based on 36 servings): 1. Fresh spinach - 2 pounds, plus 4 ounces. 2. Slivered, toasted almonds - 2 ¼ cups 3. Mandarin oranges, drained - 2 quarts, plus 1 cup 4. Poppyseed dressing, prepared - 2 ¼ cups dressing. The Mandarin Spinach Salad Analysis documented each serving provided 143.8 calories, 17.74 carbohydrates, 2.52 grams of protein, 8.14 grams of fat, 14.76 grams sugar, 266.13 milligrams of potassium, 1.29 MG iron, 59.48 MG calcium, 1.92 G fiber and 85.92 milligrams of sodium. b. Creamy Lettuce Salad (based on 36 servings)(the CDM stated it was a similar recipe with the seven-layer salad having the addition of cucumbers and bacon). 1. Lettuce salad - 3 pounds, plus 9 ½ ounces 2. Fresh tomato, chopped - 4 1/3 each 3. Fresh onion, chopped - ¾ cup 4. Diced hard cooked eggs - 3 cups 5. Salad dressing - 3 ¼ cups 6. Milk - 5 fluid ounces, plus 1 tablespoon, plus 1 ½ teaspoons 7. [NAME] sugar - ½ cup 8. Cider or white vinegar - ½ cup The Creamy Lettuce Salad Analysis documented each serving provided 70.04 calories, 9.83 grams of carbohydrate, 2.84 grams of fat, 7.21 grams of sugar, 113.48 MG potassium, 0.3 MG iron, 19.74 MG calcium, 0.78 G fiber and 215.33 milligrams of sodium. During an interview on 4/02/25 at 9:10 AM the CDM affirmed the kitchen did not have a system in place regarding substitutions and again stated the prior Dietician did not require her to document or have menu substitutions approved. She did not have an approved menu substitution exchange in the kitchen. The Substitution Policy provided by the facility dated 2001 directed the Food Services Manager (CDM), in conjunction with the Clinical Dietician, may make food substitutions as appropriate and necessary. The Food Services Manager would maintain an exchange list identifying the seven exchanges of food groups. When in doubt about an appropriate substitution, the Food Services Manager would consult the Dietician prior to making the substitution. All Substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for the substitution.

Based on observation, policy review, and staff interview the facility failed to prevent bare hands from contacting serving utensils and failed to recognize proper cold food temperatures and served 6 of 19 residents a seven-layer salad that had temperatures from 45.3 to 47.9 degrees Fahrenheit prior to serving. The facility identified a census of 31 residents. Findings include: On 4/01/25 at 10:26 AM the following kitchen observations were made: a. At 10:26 AM the Surveyor entered the kitchen and observed a large stainless steel bowl of seven-layer salad sitting on top of a cart without a cold container or ice under the bowl to keep cold. b. At 10:32 AM the Certified Dietary Manager (CDM) pureed three servings of the seven-layer salad and placed one serving in a nosey cup for Resident #4 and another serving in a small bowl for Resident #24, then placed the nosey cup and the bowl inside a cold container that sat on top the cart. c. At 10:52 AM the CDM prepared seven mechanical soft servings of the seven-layer salad and placed the mixture in a large measuring cup, placing the measuring cup inside the cold container on the cart. d. At 11:02 AM the CDM completed temperature checks on the seven-layer salad which remained sitting out on the cart. Resident #4's nosey cup of pureed seven-layer salad temped at 47.9 degrees Fahrenheit (F); Resident #24 bowl of seven-layer salad did not have a temperature check completed; the measuring cup of mechanical soft seven-layer temped at 45.3 degrees. The CDM stated at that time she planned to serve the seven-layer salad and did not place any of the seven-layer salad in the refrigerator or freezer to cool. At 11:09 AM the CDM verbalized the seven-layer salad contained cucumbers, bacon, cheese, peas, boiled eggs, lettuce, and a sugar-mayonnaise dressing. e. Observation on 4/01/25 at 11:11 AM the Certified Dietary Manager (CDM) picked up tongs from the utensil bin by the bottom of the tongs with her bare hands after touching the menu and moving to the serving table and placed in the apricot chicken. f. At 11:20 AM the CDM started plating up food for the residents. The CDM served out four servings of the mechanical soft seven-layer salad to residents #8, #15, #18, and #30. g. At 11:35 AM the CDM added a small amount of water to Resident #4 nosey cup of seven-layer salad to improve the consistency and served out the nosey cup of seven-layer salad. h. At 11:37 AM the CDM served out the bowl of seven-layer salad to Resident #24. i. Ten residents were served the apricot chicken with the soiled tongs. The CDM finished meal service at 11:55 AM and completed the following post meal temperatures: 1. Milk - 41.8 degrees 2. Mechanical soft seven-layer salad - 44 degrees. 3. Pureed salad - served out as above. On 4/01/25 at 12:01 PM the CDM voiced they use the Serv Safe training as their guide for safe food temperatures. The kitchen did not have a system in place to obtain the temperature of cold food items to ensure those food items were below 41 degrees and safe to serve prior to or during meal service. On 4/01/25 at 12:07 PM Staff M, Dietary Assistant/Cook reported cold food items should be kept below 40 degrees. She voiced the only cold food item they record a temperature for is milk. They do not do temperature checks on any cold salads and document the temperatures. On 4/01/25 at 12:08 PM the CDM reported they would implement checking cold food items and documenting the temperatures to assure food safety. She voiced she didn't realize she had touched the tongs by the end used to serve out the apricot chicken, but utensils should be handled so that bare hands do not touch the serving end. The Preventing Foodborne Illness, Food Handling Policy revised December 2008 directed food would be stored, prepared, handled and served so that the risk of foodborne illness is minimized. The Policy specified food service employee would be trained in the proper use of utensils such as tong to prevent foodborne illness. The Policy lacked direction to the staff on holding cold food temperatures and monitoring of temperatures. The Center for Medicare and Medicaid States Operation Manual, Issue Date 8/8/24 defines Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). The temperature of PHF/TCS foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperatures are maintained. Refrigerated foods are to be held at 41 degrees or colder.

Based on observation, policy review, and staff interview the facility failed to keep bare hands off the drinking surface of glasses to prevent possible contamination. The facility reported a census of 31 residents. Findings include: During an observation of the noon meal on 5/28/24 from 11:28 AM to 12:00 PM Staff A, Dietary Aide served 12 glasses to 9 residents with bare fingers touching the drinking rim surface of the glass. During an observation of the noon meal on 5/29/24 from 11:05 AM to 11:30 AM Staff B, Dietary Aide served 25 glasses to 14 residents with bare fingers touching the drinking rim surface of the glass. The facility lacked a policy regarding hand placement during dining service. In an interview on 5/29/24 at 1:06 PM Staff C, Dietary Supervisor, explained there is no policy on dining service. Staff are educated through an online program to hold cups from the side and keep the ends of the silverware wrapped. Staff must complete the education before they start working. She further explained she expected staff to touch the napkin only and not the silverware itself. They are to grab glasses from the side or the handle of a coffee cup - not where residents will drink from.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to ensure the physician documented their rationale for extending as-needed (PRN) antianxiety medication beyond 14 days, ensured there was a specific duration for the PRN order, and failed to ensure the order was reviewed timely for 3 (Residents #5, #14, and #24) of 4 residents reviewed for unnecessary medications who had a PRN order for a psychotropic medication. Findings included: Review of a facility policy titled, PRN Psychotropic Medication Prescribing and Monitoring, undated, revealed, PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the medical record and indicate the duration for the PRN orders. 1. A review of an ICD-10 Diagnosis List revealed the facility admitted Resident #14 with diagnoses that included major depressive disorder and anxiety disorder. The quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) could not be completed with Resident #14 due to being rarely/never understood. The Staff Assessment for Mental Status indicated Resident #14 had short-term and long-term memory problems and was moderately impaired with cognitive skills for daily decision making. The MDS indicated Resident #14 received antianxiety medication and exhibited verbal and physical behavioral symptoms directed towards others on one to three days of the seven-day look back period. The resident also exhibited other behavioral symptoms not directed towards others on four to six days during the seven-day look back period. A review of Resident #14's Care Plan, dated 12/02/2022, revealed Resident #14 had periods of being confused, anxious, and agitated. The Care Plan also indicated Resident #14 would yell, strike out, and be restless. A review of Resident #14's Physician Orders, signed by Attending Physician (AP) #1 on 07/25/2022, revealed an order dated 06/09/2022 for lorazepam (an antianxiety agent and sedative/hypnotic) gel 1 milligram/milliliter (mg/ml) with a dose of .5 ml, every six hours as needed for anxiety and agitation. The order indicated the use of lorazepam was to be reviewed every 60 days or as needed. A review of Resident #14's Physician Orders. signed on 01/11/2023, revealed an order dated 07/25/2022 for lorazepam gel 1 mg/ml, every six hours as needed for anxiety and agitation. The order indicated the use of lorazepam would be reviewed every 60 days or as needed and was reviewed on 07/25/2022. A review of Resident #14's medication administration record (MAR) from 11/01/2022 to 02/14/2023 revealed Resident #14 was administered PRN lorazepam on 11/27/2022, 12/01/2022, 01/18/2023, 01/23/2023, 01/29/2023, 02/06/2023, 02/08/2023 and 02/10/2023. A review of Resident #14's medical record revealed no documentation of a rationale for the continued use of lorazepam and there was no documentation to indicate the duration for the PRN order. During an interview on 02/14/2023 at 9:55 AM, the Registered Health Information Technician (RHIT) said the dates the medications were reviewed were not indicated in the PRN lorazepam order. The RHIT said that when the doctor reviewed the medication, they usually documented next to the order on the list. The RHIT agreed the order did not appear to have been reviewed after 07/25/2022. During an interview on 02/15/2023 at 10:17 AM, the Director of Nursing (DON) revealed Resident #14's PRN lorazepam order was not updated or reviewed. The review date had passed. During an interview on 02/15/2023 at 10:28 AM, the Administrator revealed PRN orders should be updated with current review dates. During an interview on 02/15/2023 at 11:42 AM, the Pharmacist revealed the primary care physician would review PRN orders. She said the dates would need to be updated when they were reviewed. 2. A review of an ICD-10 Diagnosis List revealed the facility admitted Resident #24 with diagnoses that included bipolar II disorder and Parkinson's disease. A review of Resident #24's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The MDS indicated Resident #24 received antianxiety medications. A review of Resident #24's Care Plan, dated 12/23/2022, revealed Resident #24 had the potential to feel anxious, scared, and sad. A review of a document from Resident #24's medical record, dated 01/24/2023, revealed a note to Attending Physician (AP) #2 indicating Resident #24 no longer wanted to take lorazepam (an antianxiety agent and sedative/hypnotic). The note asked if AP #2 would like to discontinue the medication or change to PRN. AP #2 responded, OK to change the order to PRN. A review of Resident #24's Physician Orders, dated 02/14/2023 but unsigned, revealed an order dated 01/25/2023 for lorazepam .5 milligram (mg) at bedtime PRN for anxiety. The order did not indicate an end date. During an interview on 02/14/2023 at 9:55 AM, the Registered Health Information Technician (RHIT) revealed the dates the medications were reviewed were not indicated in the PRN lorazepam order. The RHIT said that when the doctor reviewed the medication, they usually documented next to the order on the list. During an interview on 02/15/2023 at 10:17 AM, the Director of Nursing (DON) said Resident #24's PRN lorazepam order was not updated and should have been discontinued after 14 days. During an interview on 02/15/2023 at 10:28 AM, the Administrator said medication orders should be updated with current review dates. During an interview on 02/15/2023 at 11:42 AM, the Pharmacist said the primary care physician would review PRN orders. She said the dates would need to be updated when they were reviewed. She indicated she reviewed all orders with every monthly medication review 3. A review of an ICD-10 Diagnosis List revealed the facility admitted Resident #5 with a diagnosis that included epilepsy. Resident #5's quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #5's cognitive skills were severely impaired for daily decision making, per the Staff Assessment for Mental Status. The MDS indicated Resident #5 was dependent upon staff for all activities of daily living and received no special treatments. Review of Resident #5's Care Plan, reviewed/revised 11/22/2022, revealed the resident required monitoring for seizure activity and the use of PRN lorazepam for seizure activity. Appropriate goals and approaches for the problems were addressed in the care plan. Review of Resident #5's Physician Orders, signed on 01/11/2023, revealed an order, dated 11/03/2022, for lorazepam (an antianxiety agent and sedative/hypnotic) 2 milligrams/milliliter (mg/ml) with a dose of .5 ml/1mg by mouth as needed for seizure. The administration instructions included for seizure activity 5 minutes or longer. May repeat in 15 minutes if needed. No more than 2 mg in 24 hours. Review use of PRN Lorazepam every 60 days and/or as needed. Reviewed 11/03/2022. Review of Resident #5's Physician Orders, dated 02/14/2023 but unsigned, revealed the PRN lorazepam order was reviewed 11/03/2022. During an interview on 02/14/2023 at 12:59 PM, the Director of Nursing (DON) stated the physician/physician's assistant reviewed the physician's orders and signed them. She stated the facility considered that signature a review or extension of the PRN lorazepam order. During an interview on 02/14/2023 at 1:33 PM, the DON stated the order for Resident #5's PRN lorazepam had not been reviewed within 60 days as specified in the order. During an interview on 02/14/2023 at 2:45 PM, the Administrator stated the physician's review of Resident #5's PRN lorazepam order was late. During an interview on 02/15/2023 at 11:46 AM, the Pharmacist stated it was the facility's policy to have the primary care physician (PCP) review PRN psychotropic medication orders. She stated the PCP should review the PRN psychotropic order within the time limit designated in the order.