**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to send the CCP (Comprehensive Care Plan) goals when Resident #23 had to be transferred to the emergency room on 2/1/19. Resident #23 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to Alzheimer's disease, stroke, anxiety and depression. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/1/19, the resident was coded as having short term and long-term memory problems and was severely impaired daily decision making. Resident #23 was also coded as requiring extensive assistance with 1 staff member for dressing and personal hygiene. The resident was totally dependent on 1 staff member for bathing. During the clinical record review conducted on 3/28/19 for this resident, the surveyor noted the resident had sustained facial injuries that occurred with a fall on 2/1/19. The surveyor could not find documentation of the CCP goals being sent to the emergency room on 2/1/19. At 4:02 pm, the surveyor asked the DON (director of nursing) what information is sent with a resident when they go to the emergency room. The DON stated, transfer/discharge form, copy of the med (medication) list. We also notify the RP (Responsible Party) of the bed hold policy and notify the Ombudsman if the resident is admitted to the hospital. The surveyor asked the DON if the CCP goals are sent with the resident when they are transferred to the emergency. The DON stated that she would get back with the surveyor on this. At 4:29 pm, the [NAME] returned and stated, The care plan goals are not sent. On 3/29/19 at 11:48 am, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/29/19. Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide the comprehensive care plan goals to the receiving provider for 2 of 15 residents (Resident #15 and Resident #23). The findings included: 1. The facility staff failed to provide the receiving provider the comprehensive care plan goals for Resident #15 when the resident was admitted to the hospital 3/5/19. The clinical record of Resident #15 was reviewed 3/27/19 through 3/29/19. Resident #15 was admitted to the facility 2/21/19 with diagnoses that included but not limited to gastroesophageal reflux disease, convulsions, pain, Vitamin D deficiency, implantation of dual chambered pacemaker, non-ischemic cardiomyopathy, stage 4 CKD (chronic kidney disease), IDDM2 (insulin dependent diabetes mellitus type 2), multiple sclerosis, right bundle branch block, and hypothyroidism. Resident #15's 14 day MDS (minimum data set) assessment with an assessment reference date (ARD) of 3/21/19 assessed the resident with a BIMS (brief interview for mental status) summary score as 15/15. The interdisciplinary note dated 3/5/19 at 4:09:39 read, Left unit for cardiac procedure. The clinical record had no documentation of what information was sent with Resident #15 when the resident was admitted to the hospital 3/5/19. The surveyor interviewed the director of nursing on 3/28/19 at 4:02 p.m. The DON was asked what information was sent with residents when they are transferred to the hospital. The DON stated the facility provided the bed hold policy, transfer/discharge form, a copy of the medication list, notification to ombudsman, advanced directive, and face sheet. The DON was asked if the comprehensive care plan goals were sent with the resident to the receiving provider. The DON stated care plans were not sent. The surveyor informed the administrator, the director of nursing, the infection preventionist, and the executive director of the above concern on 3/28/19 at 5:00 p.m. and again on 3/29/19 at 11:41 a.m. No further information was provided prior to the exit conference on 3/29/19.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to administer the correct amount of eye drops to 1 of 15 residents (Resident #21). The findings included: The facility staff failed to administer the correct amount of eye drops to Resident #21 during a medication pass and pour observation. Licensed practical nurse #1 administered two (2)-eye drops of Combigan in Resident #21's right eye-not one drop as ordered. The surveyor observed a medication pass on 3/28/19 with licensed practical nurse #1 beginning at 7:51 a.m. L.P.N. #1 prepared medications for Resident #21 at the medication cart, entered the resident's room and administered the oral medications without any issues. L.P.N. #1 donned gloves. L.P.N. #1 attempted to administer Combigan 0.2-0.5% eye drops one (1) drop in the left eye but missed the eye. L.P.N. #1 then administered one drop in the left eye. L.P.N. #1 then administered two (2) drops of Combigan in the resident's right eye. L.P.N. #1 removed gloves and hands were washed. The surveyor reconciled the medications administered with the current March 2019 physician's orders. The order for the eye drops read, Combigan 0.2%-0.5% eye drops Instill 1 drop by ophthalmic (eye) route every 12 hours-unspecified glaucoma. The surveyor informed L.P.N. #1 of the observation on 03/28/19 10:00 AM L.P.N. #1 stated she thought she had only given the resident 1 drop in each eye. The surveyor informed the director of nursing of the medication observation on 3/28/19 at 10:29 a.m. and requested the facility policy on medication administration. The facility policy titled Medication Administration and Documentation read in part C. Administer the medication verifying the 6 Rights 1. Right resident 2. Right medication 3. Right dosage 4. Right route 5. Right time 6. Right documentation Resident #21 was admitted to the facility 3/11/19 with diagnoses, that included but not limited to, poisoning by other opioids, accidental, hyponatremia, hypertension, pain, allergic rhinitis, Vitamin D deficiency, glaucoma, hypothyroidism, insomnia, constipation, and urinary tract infection. Resident #21's admission MDS (minimum data set) assessment with an assessment reference date (ARD) of 3/18/19 assessed the resident with a BIMS (brief interview for mental status) summary score as 15/15. The resident was interviewable. The surveyor interviewed the resident after informing the director of nursing of the medication pass observation on 3/28/19 at 10:29 a.m. Resident #21 stated the nurse gave her one drop of her eye drops in each eye. Resident #21 did not acknowledge the missed attempt of medication in the left eye. The surveyor informed the administrator, the director of nursing, the infection preventionist, and the executive director of the above concern during the end of the day meeting on 3/28/19 at 5:00 p.m. No further information was provided prior to the exit conference on 3/29/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess for pain prior to wound care for 1 of 15 residents in the survey sample (Resident #29). The findings included: The facility staff failed to assess for pain prior to providing the wound care to Resident #29 on 3/28/19. Resident #29 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, pneumonia, dementia, anxiety disorder, depression, respiratory failure and Stage 3 pressure ulcer. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/19/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 13 out of a possible score of 15. Resident #29 was also coded as requiring limited assistance with dressing, personal hygiene and bathing. During the wound care observation made by the surveyor on 3/28/19 at 10 am, the nurse did not assess for pain prior to the performing wound care on Resident #29. The surveyor reviewed the MAR (medication administration record) for March 2019 and noted the following: .Monitor Pain using Universal Pain Assessment Tool . This pain monitoring was signed off as being carried out for the shifts of 7:00am-3:00pm, 3:00pm - 11 pm and 11pm-7:00 am. However, this pain monitoring was not specific to the time that RN (registered nurse) #1 had assessed for pain prior to the wound care that was observed by the surveyor. At 10:46 am, the surveyor notified the Infection Preventionist of the above documented findings. On 5:00 pm, the surveyor notified the administrative team of the above documented findings. The surveyor asked if the expectation by this team was for the nurses to assess for pain prior to performing wound care. The Infection Preventionist stated, Yes, I would expect them to do this before performing any procedure. No further information was provided to the surveyor prior to the exit conference on 3/29/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to have scheduled medications available for administration to 2 of 15 residents (Resident #23 and Resident #28). The findings included: 1. The facility staff failed to have a scheduled medication, Donapezil, available for Resident #23. Resident #23 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to Alzheimer's disease, stroke, anxiety and depression. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/1/19, the resident was coded as having short term and long-term memory problems and was severely impaired daily decision making. Resident #23 was also coded as requiring extensive assistance with 1 staff member for dressing and personal hygiene. The resident was totally dependent on 1 staff member for bathing. During the clinical record review on 3/28/19, the surveyor noted on the February 2019 MAR (medication administrative record) the following: . 2/16/19 9 pm .Donepezil 10 mg (milligram) tab (tablet) none available-awaiting from Rx (pharmacy) . The surveyor notified the DON (director of nursing) of the above documented findings on 3/28/19 at 5 pm in the conference room. The DON stated, I didn't realize this was not available. The surveyor notified the administrative team of the above documented findings on 3/29/19 at 11:48 am. No further information was provided to the surveyor prior to the exit conference on 3/29/19. 2. The facility failed to have a scheduled medication, Ativan, available for administration to Resident #28. Resident #28 was originally admitted to the facility on [DATE] but was redmitted to the facility on 4/11/18 with the following diagnoses of, but not limited to heart failure, high blood pressure, dementia and anxiety disorder. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/4/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 2 out of a possible score of 15. Resident #28 was also coded as requiring limited assistance for dressing, personal hygiene and bathing. During the clinical record review on 3/27/19, the surveyor noted the following on the February 2019 MAR (Medication Administrative Record): .2/11/19 9 pm .Lorazepam 0.5mg (milligram) 1 po (by mouth) unavailable to give qhs (every night at bedtime). Meds (medicine) is reordered. Pharmacy is aware . On 3/28/19 at 5 pm, the surveyor notified the administrative team of the above documented findings. The DON (director of nursing) stated, Since this medication was a controlled medicine, the pharmacy would not do an emergency run because we were out. In addition, we couldn't use the backup pharmacy because the doctor would have to give us a hard script and then call and arrange this with the backup pharmacy. The physician had ordered this medication to be administrated daily at 9 pm. The surveyor notified the administrative team of the above documented findings on 3/29/19 at 11:48 am. No further information was provided to the surveyor prior to the exit conference on 3/29/19.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow the physician orders for 1 of 15 residents (Resident #1). The findings included: The facility staff failed to follow the physician orders for an x-ray of the left hand for Resident #1. The x-ray was obtained on the right hand-not the left hand as ordered. The clinical record of Resident #1 was reviewed 3/27/19 through 3/29/19. Resident #1 was admitted to the facility 9/19/18 with diagnoses that included but not limited to arthritis of left hand, macular degeneration of both eyes, skin hemangioma, hypothyroidism, ovarian failure, hyperlipidemia, Alzheimer's disease, anxiety, depressive disorder, osteopenia, hiatal hernia, and Parkinson's. Resident #1's significant change in minimum data set (MDS) assessment with an assessment reference date (ARD) of 12/26/18 assessed the resident with a BIMS (brief interview for mental status) as 8/15. An order dated 11/5/18 read in part X-ray of L (left in a circle) hand pain/swelling 3rd digit. A review of the laboratory section/radiologic section revealed the results of a right hand x-ray completed 11/5/18. The surveyor was unable to locate the x-ray results for the left hand. The surveyor informed the director of nursing of the above concern on 3/28/19 at 3:57 p.m. The surveyor informed the administrator, the director of nursing, the infection preventionist, and the executive director of the above concern during the end of the day meeting on 3/28/19 at 5:00 p.m. and again 3/29/19 at 11:41 a.m. and in addition, requested the facility contract with the x-ray company. The contract with the x-ray company read in part 2.2.4 only perform tests as requested in writing by a physician on a test requisition form. The DON stated the x-ray technician did the x-ray on the wrong hand. No further information was provided prior to the exit conference on 3/29/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview facility document review, and clinical record review, the facility staff failed to follow infection control guidelines for wound care for 1 of 15 residents (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, pneumonia, dementia, anxiety disorder, depression, respiratory failure and Stage 3 pressure ulcer. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/19/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 13 out of a possible score of 15. Resident #29 was also coded as requiring limited assistance with dressing, personal hygiene and bathing. During the wound care observation made by the surveyor on 3/28/19 at 10 am, the surveyor observed RN (registered nurse) #1perform a dressing change to the coccyx area of Resident #29. RN #1 placed a paper towel on the counter beside the sink. This surveyor did not observe RN #1 cleaning this area prior to putting paper towels down as a barrier. RN #1 washed her hands and applied clean gloves. The old dressing was removed from the area on the coccyx and a clean 4x4 that was folded by the RN was moistened with sterile water. RN #1 cleaned the wound by using a patting method up and down the wound from the top to the bottom. The nurse did not change gloves nor wash her hands prior to applying the clean dressing. RN #1 cut the clean Xerofoam with scissors that she took out of her pocket. RN #1 continued to wear the gloves that she wore when removing the old dressing from the resident's wound. At 1:30 pm, the infection control nurse was notified of the above documented findings that the surveyor observed during the dressing change to Resident #29. The infection control nurse stated, She should had taken her gloves off after she removed the old dressing and washed her hands. The surveyor notified the administrative team of the above documented findings on 3/28/19 at 5 pm in the conference room. The surveyor requested copies of the facility's policies on infection control while performing a dressing change. On 3/29/19, the surveyor received a copy of the facility's policy titled Dressings, Dry/Clean which read in part: .Establish a clean field . Loosen tape and remove old dressing. Pull glove over dressing and discard into a plastic or biohazard bag. Wash and dry your hands thoroughly. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface . If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward) . No further information was provided to the surveyor prior to the exit conference on 3/29/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to monitor targeted behaviors while Resident #20 was receiving Ativan and Restoril. Resident #20 was admitted to the facility on [DATE] with the following diagnoses, but not limited to cancer, heart failure, high blood pressure, thyroid disorder, anxiety and depression. On the admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/13/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #20 was also coded as requiring extensive assistance of 1 staff member for dressing and limited assist of 1 staff member for personal hygiene. The resident was coded as being totally dependent on 1 staff member for bathing. During the clinical record review, the surveyor noted physician's orders for Ativan 0.25 milliliter by mouth three times a day as needed for 14 days for anxiety and Restoril 15 mg (milligrams) by mouth once daily as needed at bedtime for 14 days for sleep. The Ativan had a start date of 3/8/19 and the Restoril had a start date of 3/1/19. The surveyor reviewed the clinical record and could not find any behavior monitoring for the targeted behaviors that the staff was to monitor while a resident was on Restoril and Ativan. On 3/29/19 at approximately 10 am, the surveyor notified the DON (Director of Nursing) that the surveyor could not find any behavior monitoring for the Restoril and Ativan that Resident #20 had been ordered and given. The DON stated, We monitor the behaviors for the first 7 days then it is stopped. We don't continue the monitoring after that. On 3/29/19 at 11:48, the surveyor notified the administrative team of the above documented findings. No further information was provided to the surveyor prior to the exit conference on 3/29/19. 4. The facility staff failed to monitor targeted behaviors while Resident #22 was receiving Cymbalta and Temazepam. Resident #22 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, anxiety, depression and insomnia. On the significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/27/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 6 out of a possible score of 15. Resident #22 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and was totally dependent on 1 staff member for bathing. During the clinical record review on 3/29/19, the surveyor noted that the physician had ordered Cymbalta 60 mg (milligram) by oral (mouth) route once daily for anxiety disorders and Temazepam 15 mg give 1 capsule by oral route daily at bedtime. These medications were originally ordered by the physician on 8/1/18 and was renewed by the physician on 3/7/19. The surveyor reviewed the clinical record for behavior monitoring of the targeted behaviors for these medications. On 3/29/19 at approximately 11 am, the surveyor notified the DON (director of nursing) of the above documented findings. The DON stated, We monitor the behaviors for the first 7 days then it is stopped. We don't continue the monitoring after that. The administrative team was notified of the above documented findings at 11:48 in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/29/19. 5. The facility staff failed to monitor targeted behaviors while Resident #23 was receiving Celexa and Clonazepam. Resident #23 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to Alzheimer's disease, stroke, anxiety and depression. On the annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/1/19, the resident was coded as having short term and long-term memory problems and was severely impaired daily decision making. Resident #23 was also coded as requiring extensive assistance with 1 staff member for dressing and personal hygiene. The resident was totally dependent on 1 staff member for bathing. During the clinical record review on 3/29/19, the surveyor noted the that the physician had ordered Celexa 20 mg (milligram) 1 tablet by mouth daily for depressive episodes and Celexa 0.5 mg 1 tablet by mouth daily for anxiety disorder. There were no monitoring of targeted behaviors while the resident was receiving these medications. The surveyor notified the DON (director of nursing) was notified of the above documented findings at approximately 11 am. The DON stated, We monitor the behaviors for the first 7 days then it is stopped. We don't continue the monitoring after that. The surveyor notified the administrative team of the above documented findings at 11:48 am in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/29/19. 6. The facility staff failed to monitor targeted behaviors while Resident #31 was receiving Remeron, Zoloft and Abilify. Resident #31 admitted to the facility on [DATE] with the following diagnoses of, but not limited to dementia, depression and Schizophrenia. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/8/19, coded the resident as requiring extensive assistance of 1 staff member for dressing, personal hygiene and bathing. Resident #31 was also coded as having short term and long term memory problems with being severely impaired in making daily decisions. During the clinical record review on 4/4/19, the surveyor notes that the physician had ordered Remeron 15 mg (milligram) 1 tablet by mouth daily before bedtime, Zoloft 125 mg by mouth daily in the mornings and Abilify 2 mg by mouth daily for mood disorder. The surveyor reviewed the MAR (medication administration record) for February and March 2019 and noted the following: .Monitor for targeted behaviors and/or side effects utilizing the facility's Behavioral and Side Effect Monitoring flow sheet for psycho-tropic medication use . There were nurses' initial in the boxes on the MAR as being monitored for the shifts of 7am -3 pm, 3pm -11pm and 11pm -7 am. There were no specific targeted behaviors for the nurse to monitor for Resident #31 while receiving the above documented medications. The surveyor notified the DON (director of nursing) of the above documented findings at 11:07. The DON stated, We monitor the behaviors for the first 7 days then it is stopped. We don't continue the monitoring after that. The surveyor notified the administrative team of the above documented findings at 11:48 am in the conference room. No further information was provided to the surveyor prior to the exit conference on 3/29/19. Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure 6 of 15 residents were free of unnecessary psychotropic medications that affected Resident #3, Resident #19, Resident #20, Resident #22, Resident #23, and Resident #31. The findings included: 1. The facility staff failed to monitor behaviors associated with the use of Sertraline for Resident #3. The clinical record of Resident #3 was reviewed 3/27/19 through 3/29/19. Resident #3 was admitted to the facility 3/6/17 with diagnosis that included but not limited to benign intracranial hypertension, encephalopathy, dysphagia, dysarthria and anarthria, non-traumatic intracranial hemorrhage, cognitive deficits following cerebrovascular disease, hypertension, major depressive disorder, hypothyroidism, pain, and neuromuscular dysfunction of the bladder. Resident #3's quarterly MDS (minimum data set) assessment with an assessment reference date (ARD) of 12/27/18 assessed the resident with a BIMS (brief interview for mental status) as 3/15. Resident #3 was not assessed with any signs or symptoms of delirium, no behaviors that affected others, and no indicators of psychosis. Resident #3's March 2019 physician's orders read in part Sertraline 50 mg (milligrams) tablet give 1 tablet (50 mg) by oral route once daily. The current comprehensive care plan dated 4/8/18 identified Psychotropic Drugs as a concern. The care plan read in part Resident #3 is on psychotropic medication related to anxiety and depression. (G) Resident #3 will be free of depressive behaviors and adverse effects of med through the review date. (A) Monitor and document all behaviors related to depression such as episodes of tearfulness, withdrawal from friends/family. (A) Monitor and document side effects of antidepressant such as lethargy, irritability, excitability, constipation, dry mouth. Monitor for least effective dose. The surveyor was unable to locate any evidence of monitoring of the targeted behaviors associated with the use of Sertraline. The surveyor informed the director of nursing (DON) of the above concern on 3/29/19 at 9:33 a.m. and requested the monitoring sheets for Sertraline. The DON stated, We don't monitor antidepressants, hypnotics or antianxiety medications-only antipsychotics. The surveyor requested the facility policy on psychotropic medications on 3/29/19. The facility policy titled Psychotropic Drugs read in part: Individuals who are prescribed psychotropic drugs shall be regularly and systematically assessed and evaluated for tardive dyskinesia. The policy did not contain any other information about psychotropic medications other than tardive dyskinesia. The surveyor informed the administrator, the director of nursing, the infection preventionist, and the executive director of the above concern in the end of the survey meeting on 3/29/19 at 11:41 a.m. No further information was provided prior to the exit conference on 3/29/19. 2. The facility staff failed to monitor resident specific targeted behaviors, offer/implement non-pharmacological interventions prior to the use of Flurazepam, and monitor for side effectsassociated with the use of the hypnotic Flurazepam for Resident # 19. The clinical record of Resident #19 was reviewed 3/27/19 through 3/29/19. Resident #19 was admitted to the facility 3/6/19 with diagnoses that included but not limited to insomnia, dementia with behavioral disturbances, chronic diastolic heart failure, atherosclerotic heart disease, chronic kidney disease, stage 3, fall, contusion of right eyelid and periocular area, hypertension, paroxysmal atrial fibrillation, type 2 diabetes mellitus, mitral stenosis, gastroesophageal reflux disease, acute pain due to trauma, and hyperlipidemia. Resident #19's fourteen (14) day MDS (minimum data set) assessment with an assessment reference date (ARD) of 3/20/19 assessed the resident with a BIMS (brief interview for mental status) summary score as 15/15. There were no assessed signs or symptoms of delirium, psychosis, or behaviors affecting others. The current comprehensive care plan dated 3/19/19 identified an area that read: Psychotropic Drugs-Resident requires us of Psychotropic Medication to manage insomnia-see insomnia CP (care plan). Alteration in sleep pattern related to insomnia. The care plan identified attempts to manage environment as able-minimize noise and light, allow soft music, use scent cammomille (sic), lavender for relaxation, soft soothing music. Manage comfort level-warm milk, position with pillows, back rub, pain control. Administer hypnotic, antianxiety or antidepressant as ordered-see POS (physicians order sheet) for med (medication), dose, and schedule. Assess effectiveness of med on sleep patterns. Resident #19's March 2019 physician's orders included the order for Flurazepam 15 mg (milligrams) give 1 capsule by oral route once daily at bedtime for 14 days as needed for insomnia-order date 3/6/19. A second order dated 3/18/19 read Flurazepam 15 mg capsule give 1 capsule (15 mg) by oral route once daily at bedtime for insomnia. A review of the March 2019 medication administration record (MAR) revealed Resident #19 received prn Flurazepam every night from 3/6/19 through 3/17/19. The surveyor found no non-pharmacological interventions prior to the use of the medication documented on the reverse side of the March 2019 MAR. A review of the interdisciplinary notes indicated there were no non-pharmacological interventions prior to the use of the medication. 3/7/19 2:49:21 interdisciplinary note read Flurazepam given for insomnia at 2330 (11:30 p.m.). No non-pharmacological interventions offered or documented prior to use on the March MAR or in the interdisciplinary notes. 3/8/19 March MAR read Flurazepam 15 mg insomnia (reason) 9P. No non-pharmacological interventions offered or documented prior to use on the March MAR or in the interdisciplinary notes. 3/9/19 21:30:46 (9:30:46 p.m.) interdisciplinary note read Medicated for pain and insomnia. No non-pharmacological interventions offered or documented prior to use on the March MAR or in the interdisciplinary notes. 3/10/19 March MAR read Flurazepam 15 mg insomnia (reason) 9P. Rsd request for sleep. No non-pharmacological interventions offered or documented prior to use on the March MAR or in the interdisciplinary notes. 3/11/19 March MAR read Flurazepam 15 mg insomnia (reason) 9P. Rsd request for sleep. No non-pharmacological interventions offered or documented prior to use on the March MAR or in the interdisciplinary notes. 3/12/19 March MAR read Flurazepam 15 mg insomnia (reason) 9P. Requested for sleep. No non-pharmacological interventions offered or documented prior to use on the March MAR or in the interdisciplinary notes. 3/13/19 01:43:11 note read in part Rsd (resident) requested pain medication and sleep medication @ (at) 9pm d/t (due to) facial pain and chronic insomnia. Rsd (resident) given prn Flurazepam 15 mg to help with noted pain to face and insomnia. No non-pharmacological interventions offered or documented prior to use. 3/13/19 22:43:30 (10:22:30 p.m.) read in part PRN pain medication and PRN insomnia medication requested by resident; both administered at HS (bedtime). No non-pharmacological interventions offered or documented prior to use. 3/15/19 March MAR read Flurazepam 15 mg insomnia (reason) 9P. Rsd request-sleep. No non-pharmacological interventions offered or documented prior to use. 3/16/19 March MAR read Flurazepam 15 mg insomnia (reason) 9P. Insomnia qhs. No non-pharmacological interventions offered or documented prior to use. 3/17/19 02:24:10 a.m. interdisciplinary note read in part Rsd requested PRN Percocet 5/325 mg + Flurazepam 15 mg @ 9pm (QHS-every bedtime) for facial pain and insomnia. Rsd requests these each evening QHS. Noted in MD (medical doctor) communication book about considering scheduling medications at bedtime d/t (due to) use. No non-pharmacological interventions offered or documented prior to use. The medication was ordered for nightly administration on 3/18/19 and the staff monitored the medication Flurazepam nightly from 3/18/19 through 3/25/19 to include targeted behaviors. The monitoring of the hypnotic was done for 1 week and then stopped. The director of nursing was notified of the above concern on 3/29/19 at 10:47 a.m. The DON stated the staff monitor for 7 days and then stop. The DON stated the staff do not monitor antidepressants, antianxiety medications or hypnotics. The DON stated the staff do monitor antipsychotic medications. The surveyor informed the administrator, the director or nursing, the infection preventionist and the executive director of the above concern on 3/29/19 at 11:41 a.m. No further information was provided prior to the exit conference on 3/29/19.