Every finding on record at Shaire Nursing Center

Based on record reviews and staff interviews, the facility failed to ensure residents were offered the COVID-19 vaccination for 5 of 5 residents reviewed for immunizations (Resident #3 Resident #4, Resident #9, Resident #24 and Resident #45).The findings included:A review of the Center for Disease Control (CDC) guidelines, dated 11/19/25, indicated that the CDC recommended a 2025 to 2026 COVID-19 vaccine for individuals that were age [AGE] and older, were at high risk for severe COVID-19, or had never received a COVID-19 vaccine. a. Resident #3 was admitted to the facility on [DATE].Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #3 had severe cognitive impairment and was not up to date for COVID-19 immunization.Review of Resident #3's electronic medical record revealed the last COVID-19 immunization given to the Resident was 01/06/22 before her admission to the facility. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #3 or education had been provided to Resident #3 regarding the benefits and potential side effects of the COVID-19 vaccine.b. Resident #4 was admitted to the facility on [DATE].Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #4 was cognitively intact and was not up to date for COVID-19 immunization.Review of Resident #4's electronic medical record revealed the last COVID -19 immunization given to the Resident was 05/26/23 before her admission to the facility. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #4 or education had been provided to Resident #4 regarding the benefits and potential side effects of the COVID-19 vaccine.c. Resident #9 was admitted to the facility on [DATE].Review of the annual Minimum Data Set assessment dated [DATE] revealed Resident #9's cognition was moderately impaired and was not up to date for COVID-19 immunization.Review of Resident #9's electronic medical record revealed the last COVID-19 vaccine given to Resident #9 was 11/20/23 before admission to the facility. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #9 or education had been provided to the Resident regarding the benefits and potential side effects of the COVID-19 vaccine.d. Resident #24 was admitted to the facility on [DATE].Review of the admission Minimum Data Set assessment dated [DATE] revealed Resident #24 was cognitively intact and was not up to date for COVID-19 immunization.Review of Resident #24's electronic medical record revealed the last COVID-19 vaccine was given to Resident #24 was 09/28/21 before admission to the facility. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #24 or education had been provided to the Resident regarding the benefits and potential side effects of the COVID-19 vaccine.e. Resident #45 was admitted to the facility on [DATE].Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 was cognitively intact and was not up to date for COVID-19 immunization.Review of Resident #45's electronic medical record revealed the last COVID-19 vaccine was given to Resident #45 was 01/31/23 before admission to the facility. There was no documentation in the medical record that indicated the COVID-19 vaccine had been offered to Resident #45 or education had been provided to the Resident regarding the benefits and potential side effects of the COVID-19 vaccine.An interview was conducted with the Infection Preventionist (IP) on 09/10/26 at 2:10 PM. The IP explained that she obtained the residents' COVID-19 vaccination history on admission and documented it in their medical record. The IP continued to explain that she did not obtain consents or declinations of the COVID-19 vaccinations for 2025-2026 because she was not aware that the COVID-19 vaccinations had to be offered every year.An interview was conducted with the Director of Nursing (DON) on 09/11/26 at 1:50 PM. The DON explained that she did not know that the COVID-19 vaccination should be offered every year. The DON stated she thought that if the physician deemed it necessary to give the COVID-19 vaccination then the facility would obtain the consent and ensure that the vaccination was given to the Resident.

Based on observation, record review, staff and resident interviews, the facility failed to assess for the ability to self-administer medications for 2 of 2 residents reviewed for self-administration of medications (Resident #24 and Resident #14). The findings included: 1. Resident #24 was admitted to the facility on [DATE]. Review of Resident #24's physician orders revealed there were no orders for fluocinonide 0.05 % topical solution medication (used for scalp itching and irritation). There was an order dated 07/27/2026 for topical triple antibiotic (Neomycin-Bacitracin-Polymyxin) ointment to be applied as needed for lip sores and kept at bedside for the resident to apply. Review of Resident #24's medical record revealed he had not been assessed for self administration of medication. Resident #24's comprehensive Minimum Data Set (MDS) assessment dated [DATE] showed he was cognitively intact On 09/08/2026 at 1:33 PM an observation and interview were conducted with Resident #24 in his room. An opened 60 milliliter (mL) bottle of fluocinonide 0.05 % topical solution (approximately 2/3 full) and an opened 2-ounce tube of triple antibiotic ointment (approximately 3/4 full) were observed on his nightstand. Resident #24 stated these medications were used as needed for scalp and lip irritation and that family supplied them. Resident #24 could not recall the last use of either medication. During an interview on 09/10/2026 at 9:15 AM, Nurse #2 reported she was aware of the triple antibiotic ointment located at bedside for resident self administration and she had requested the physician's order for medicine to be kept at beside for resident to administer. Nurse #2 reported that she was not aware Resident #24 also had the bottle of fluocinonide scalp drops in his room. Nurse #2 stated that she did not complete a self-administration assessment. During an interview on 09/11/2026 at 8:55 AM, the Physician Assistant (PA) reported he was not aware that a self-administration assessment by an interdisciplinary team must be completed before a resident could self-administer medications or store them at bedside. The PA reported relying on nursing notification of such requests and entered orders for residents he believed capable of self administration based on interactions during visits. During an interview on 09/11/2026 at 10:10 AM, the Director of Nursing (DON) stated that she expected nurses to remove bedside medications until a provider order was entered. The DON stated she was not aware an interdisciplinary team discussion and assessment for self-administration of medication was required before a resident could keep medications at bedside and self-administer them. During an interview on 09/11/2026 at 12:15 PM, the Administrator stated he was not aware that residents required a self-administration assessment before keeping medications at the bedside or self administering medications. The Administrator stated it was his expectation that the interdisciplinary team complete the self-administration assessment before approving bedside storage. 2. Resident #14 was admitted to the facility on [DATE] with diagnoses that included allergic rhinitis (inflammation and swelling of the mucus membrane inside the nose). Resident #14 had a physician order dated 09/06/25 that medications may be left at bedside. Resident #14's physician orders revealed an order dated 05/11/26 for ipratropium bromide solution 0.06% (an anticholinergic (a substance that blocks the action of acetylcholine) prescription medication used to reduce runny nose caused by allergies, non-allergic rhinitis or common cold) two sprays in both nostrils three times a day before meals. Resident #14's quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. Resident #14's Medication Administration Record (MAR) for 09/2026 revealed the ipratropium bromide nasal spray was documented as administered three times a day. Review of Resident #14's medical record revealed there was no assessment to self-administer medications. Review of Resident #14's medical record revealed there was no care plan to self-administer medications. On 09/08/2026 at 11:18 AM an interview and observation were made of Resident #14 in her room. The Resident had a bottle of ipratropium bromide nasal spray on her bedside table next to her bed. Resident #14 stated she used it three times a day because it helped her runny nose. On 09/09/26 at 11:49 AM a second observation was made of the ipratropium bromide nasal spray on Resident #14's bedside table. On 09/09/2026 at 1:55 PM an interview was conducted with Nurse #1 who explained that Resident #14 had an order to keep the ipratropium bromide nasal spray at her bedside and could administer the nasal spray herself. She stated that when she administered medications to Resident #14, she always asked the Resident if she administered the nasal spray then she would document it on the MAR. The Nurse continued to explain that when the residents wanted to self-medicate, the nurses had to complete an assessment to evaluate if the resident was able to self-medicate. Nurse #1 looked in Resident #14's medical record for the assessment to self-medicate but could not find one. On 09/09/2026 at 2:05 PM Nurse #1 observed the ipratropium bromide nasal spray on Resident #14's bedside table. During an interview with the Director of Nursing on 09/09/26 at 2:08 PM, she explained that if a resident wanted to self-medicate the physician would assess the resident and document the assessment in their progress notes that the resident was mentally and physically able to self-medicate. An interview was conducted on 09/11/26 at 8:55 AM with the Physician Assistant (PA) who explained that he did not document self-administration assessments and safety decisions in his clinical notes because it was unrelated to the focused visit and was not a billable service. He continued to explain that it would be inappropriate to conduct a visit solely to document indications or contraindications for self-administering medications. A second interview was conducted with the Director of Nursing (DON) on 09/11/26 at 1:15 PM. The DON reported she was not aware that the residents had to have an assessment documented in their medical record that they were mentally and physically able to self-medicate.

Based on record review, staff and Resident interviews, the facility failed to ensure a clinical assessment of injury was completed prior to transferring a resident by a mechanical lift after a fall. This deficient practice affected 1 of 3 residents reviewed for falls (Resident #45).Findings included:Resident #45 was admitted to the facility on [DATE] with diagnoses that included cardiomegaly (enlarged heart) and diabetes mellitus.Resident #45's quarterly Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and was dependent on rolling from side to side, transferring and ambulation and required a wheelchair.Review of Resident #45's care plan revised on 06/22/25 revealed the Resident was at risk for falls related to a self-care performance deficit. The goals that Resident #45 would maintain her current level of function and that she would be free of minor injury would be attained by utilizing interventions that included using a total lift for transfers, encouraging the Resident to use the call light for assistance and bringing the Resident to common areas for supervision.Review of a Facility Reported Incident (FRI) dated 09/06/25 and completed by the Administrator revealed Resident #45 fell on the floor during the early morning hours of 09/06/25. The Resident was found by Nurse Aide (NA) #1 who asked NA #2 to retrieve the total lift and the two nurse aides got Resident #45 off the floor using the total lift without notifying Nurse #3 so that a clinical assessment could be completed.Review of a printed document of a recorded statement made by Nurse #4 dated 09/06/25 revealed Nurse #4 performed a skin assessment on Resident #45 the morning of 09/06/25 and there were no injuries related to the Resident's fall on 09/06/25. On 09/08/26 at 11:38 AM an interview was conducted with Resident #45 about the fall on 09/06/25. The Resident explained that 09/06/25 was a long time ago and she has had several falls since that time. The Resident stated she remembered she was half on the bed and half off the bed when NA #1 found her and got her off the floor, so she did not really fall. Resident #45 could not recall if another nurse aide was present when NA #1 got her off the floor. Resident #45 stated she did not get hurt.During a telephone interview with NA #1 on 09/10/26 at 8:45 AM the NA explained that on 09/06/25 she walked by Resident #45's room while making rounds and saw the Resident lying on the floor wedged between the bed and her recliner. The Resident had been in bed and stated she was going to the bathroom. NA #1 continued to explain that when she found Resident #45, she immediately asked NA #2 to get the total lift so that they could get her up because of the position the Resident was in while lying on the floor. NA #1 reported that they had to roll Resident #45 from side to side to position the lift pad under her to get the Resident in position for lifting her off the floor with the total lift. The NA explained that after they got Resident #45 positioned in the wheelchair, the Resident slid out again almost to the floor and they had to reposition the Resident again in the wheelchair. NA #1 continued to explain that she took Resident #45 to the nursing station where Nurse #3 was and reported to the Nurse about having to get the Resident off the floor. The NA stated she did not inform Nurse #3 that Resident #45 was on the floor before they (NA #1 and NA #2) moved and transferred the resident because she was in the middle of rounds and call lights were going off and she had to hurry. She also stated that her main concern was getting the Resident off the floor because the Resident looked uncomfortable the way she was lying.A telephone interview was conducted with Nurse #3 on 09/10/26 at 10:45 AM. The Nurse explained that the fall in question on 09/06/25 involving Resident #45 happened over a year ago and she dealt with numerous falls a month. She stated it was not uncommon for the staff to bring Resident #45 to the nursing desk to sit with her because the Resident was always trying to climb out of bed. Nurse #3 stated she did not remember anything about Resident #45's fall from over a year ago but if she was informed of a fall then there would be an incident report about the fall because she always completed incident reports when there were falls.A telephone interview was conducted at 4:59 PM on 09/10/26 with NA #2. The NA explained that NA #1 informed her during the night on 09/06/25 that Resident #45 was on the floor and to get the total lift. She continued to explain that when she went into the room the Resident was lying on the floor at the end of the bed and the recliner. The Resident had been in bed. The Resident looked like she was in an uncomfortable position, and they had a difficult time getting the lift pad underneath her to use the total lift to transfer Resident #45 into her wheelchair. NA #2 reported that after the two NAs got the Resident into the wheelchair, NA #1 took Resident #45 to the nursing station where Nurse #3 was seated. NA #2 explained that she was trained to notify the Nurse when a resident fell, but she was too worried about getting Resident #45 off the floor and into the wheelchair.During an interview with the Director of Nursing (DON) on 09/11/26 at 1:41 PM, the DON explained that there was not an incident report about Resident #45's fall on 09/06/25. She stated she knew that the fall had happened because she and the Administrator investigated the fall but apparently she forgot to look for the incident report at the time because she would have had Nurse #3 complete the incident report. She stated the NAs should have notified Nurse #3 that Resident #45 had fallen out of bed so that the Nurse could assess the Resident before she was transferred into her wheelchair. The DON reported that the Resident had no injuries related to the fall. During an interview with the Administrator on 09/11/26 at 2:15 PM, the Administrator explained that he found out about Resident #45's fall that occurred on 09/06/25 when he and the DON investigated a different issue. He continued to explain that Resident #45 had no injuries related to the fall because there was a skin assessment completed the morning of 09/06/25 on the Resident and no injuries were identified. The Administrator stated the NAs should have notified the Nurse before they moved Resident #45 so that the Resident could be assessed for injuries due to the fall.

Based on observations, record review, staff and resident interviews, the facility failed to obtain a physician order for the size of an indwelling urinary catheter for 1 of 1 resident reviewed for urinary catheters (Resident #7). The findings included:Resident #7 was admitted to the facility on [DATE] with diagnoses that included obstructive uropathy (a blockage or hinderance in the flow of urine from the kidneys through the ureters and into the bladder, and then out through the urethra).Resident #7's quarterly Minimum Data Set assessment dated [DATE] revealed the Resident was cognitively intact and had an indwelling urinary catheter.Review of Resident #7's care plan dated 06/16/26 revealed a goal that the Resident would remain free of catheter related trauma through interventions such as following the catheter care policy and monitoring for signs and symptoms of pain, infection and trauma.Resident #7 had a physician order dated 07/26/26 to change the urinary catheter every 30 days on the evening shift. There was no order for the size of urinary catheter.Review of Resident #7's Treatment Administration Record for 08/2026 indicated the Resident's urinary catheter was last changed on 08/21/26 by Nurse #2.An interview and observation were made with Resident #7 on 09/08/26 at 2:16 PM. The Resident was sitting in his wheelchair and had an indwelling urinary catheter bag anchored on the bottom of his wheelchair. The Resident explained that the facility tried to remove his catheter, but he could not void without the catheter, so they had to replace it.An interview was conducted with Nurse #2 on 09/10/26 at 4:15 PM. The Nurse was asked to locate the order for Resident #7's urinary catheter but could not locate the order. The Nurse explained that he changed the Resident's catheter last month (08/21/26) and used same size that he removed which was a size #16 catheter. An interview was conducted with Nurse #3 on 09/10/26 at 4:20 PM who was Nurse #2's coworker and Nurse #2 asked Nurse #3 to locate the order for the size of Resident #7's catheter. Nurse #3 looked in Resident #7's medical record for the order of the size of Resident #7's urinary catheter. Nurse #3 could not find an order and explained that there should be a physician's order for the size of catheter so that nurses were not using multiple sizes of urinary catheters. During an interview with the Director of Nursing (DON) on 09/11/26 at 1:34 PM the DON explained that there should be an order for the size of the urinary catheter and looked in Resident #7's medical record to locate the order but the DON could not find the order. The DON continued to explain that it was the Wound Nurse's responsibility to audit the urinary catheters and that included to have a specific order for the size of the urinary catheter. She stated she did not know if the Wound Nurse had a system as to how often she audited the orders, but the Wound Nurse should have found that there was no order for the catheter size. The DON indicated it was important to have a specific order for the size of the catheters so that the nurses were not using multiple sizes.The Wound Nurse was unable to be interviewed.

Based on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 of 4 residents observed during the medication administration (Resident #12 and Resident #46).The findings include:A review of Novolog Flex Pen manufacturer instructions stated in part, Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing, turn the dosage dial to 2 units, hold your NovoLog Flex Pen with the needle pointing up, tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. With the needle pointing upwards, press the push-button all the way in. The dose selector will return to zero. A drop of insulin should appear at the needle tip.1. Resident #12 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus.Review of Resident #12's medical record revealed an order dated 6/8/25 for Novolog aspart insulin injection solution 100 unit per milliliter (ml), inject 4 units subcutaneously before meals for diabetes mellitus, hold for blood sugar less than 150.On 9/10/26 at 11:04 AM an observation was made of Nurse #1 preparing to administer insulin to Resident #12 via an insulin pen. The Nurse removed the Novolog insulin pen from the medication cart and set the counter to 4 units. Nurse #1 administered the 4 units of insulin without priming the insulin pen.An interview was conducted with Nurse #1 on 9/10/26 at 1:30 PM. The Nurse was asked to explain the procedure when giving insulin using an insulin pen and Nurse #1 stated that the new needle tip, then she dials up the number of units and administers it. Nurse #1 stated she was not aware the needle needed to be primed to remove the air bubbles. When the Nurse was asked how she removed the air bubbles from the needle Nurse #1 replied before today I didn't think of that air in the needle. During an interview with the Director of Nursing (DON) on 9/10/2026 at 2:30 PM, the DON stated that she was aware that Nurse #1 did not prime the insulin pen before she administered the insulin to Resident #12. The DON stated she was not aware that the insulin pens needed to be primed.2. Resident #46 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus.Review of Resident #46's medical record revealed an order dated 6/8/26 for insulin aspart injection solution 100 units/ml, inject 10 units subcutaneously three times a day for diabetes mellitus, hold for a blood sugar less than 150.On 9/10/26 at 11:17 AM an observation was made of Nurse #2 preparing to administer insulin to Resident #46 via an insulin pen. The Nurse removed the Novolog insulin pen from the medication cart and set the counter to 10 units. Nurse #1 administered the10 units of insulin without priming the insulin pen.An interview was conducted with Nurse #2 on 9/10/26 at 2:15 PM. The Nurse was asked to explain the procedure when giving insulin using an insulin pen and Nurse #2 stated that she dials up the number of units to be given and administers it. Nurse #2 stated she was not aware the needle needed to be primed to remove the air bubbles. When the Nurse was asked how she removed the air bubbles from the needle, Nurse #2 replied that she had not previously considered that there was air in the needle tip.During an interview with the Director of Nursing (DON) on 9/10/2026 at 2:30 PM, the DON stated that she was aware that Nurse #2 did not prime the insulin pen before she administered the insulin to Resident #46. The DON stated she was not aware that the insulin pens needed to be primed.

Based on observations, record reviews and staff interviews, the facility failed to implement their Infection Control policy and procedures when Nurse #2 failed to change his gloves and sanitize his hands after he removed a dirty dressing saturated with greenish yellow drainage. Nurse #2 also failed to sanitize his hands after he removed his dirty gloves before he applied a clean pair of gloves to complete the wound care procedure. This deficient practice occurred for 1 of 7 staff members observed for infection control practices (Nurse #2).The findings included:Review of the facility's undated Handwashing/Hand Hygiene policy revealed: Hand hygiene is the primary means for preventing healthcare-associated infection and the transmission of multidrug-resistant organisms. This facility requires strict adherence to evidence-based hand hygiene practices for all personnel, including licensed, unlicensed, contracted, therapy, dining, housekeeping, volunteers and students. Indications for Hand Hygiene: e. after exposure to blood, body fluids, excretions, or contaminated surfaces, h. after glove removal.On 09/09/26 at 3:23 PM an observation was made of Nurse #2 performing a dressing change on Resident #20's right hip wound. The Nurse removed the dressing from the Resident's right hip which had a thick layer of greenish yellow drainage then used both gloved hands to fold the saturated dressing and threw the dressing into the trash can. Then without removing his soiled gloves and sanitizing his hands, Nurse #2 proceeded to pick up the clean gauze and wound cleanser and cleanse the wound, then threw the gauze in the trash can. Nurse #2 then removed his dirty gloves and without using hand sanitizer or washing his hands he applied a clean pair of gloves and applied the ordered dressing to Resident #20's right hip wound. The Nurse then removed his gloves and washed his hands.An interview was conducted with Nurse #2 on 09/09/26 at 3:41 PM. The Nurse was asked to review the steps of the dressing change procedure, but the Nurse stated that he changed the dressing the way he always performed dressing changes, and he did not think he missed any steps. Nurse #2 stated that he performed the same dressing change in front of the Infection Preventionist the previous week, and he was not told that he had done anything wrong with the procedure. The Nurse stated he knew that his hands were considered dirty when he removed the old dressing, but he thought that he removed his gloves and washed his hands before he applied a clean pair of gloves.On 09/09/26 at 3:54 PM an interview was conducted with the Infection Preventionist (IP). The IP explained that Nurse #2 should have removed his gloves and sanitized his hands after he removed the old dressing from Resident #20's right hip and the Nurse should have sanitized his hands before he applied a clean pair of gloves. The IP stated she was with Nurse #2 when he changed Resident #20's dressing the week prior and when she thought about the procedure, she stated that she could not be positive that Nurse #2 sanitized his hands between glove changes. The IP stated Nurse #2 would be educated again on the procedure.During an interview with the Director of Nursing (DON) on 09/11/26 at 1:26 PM, the DON explained that Nurse #2 should have removed his gloves, sanitized his hands and applied a clean pair of gloves after he removed the old dressing from Resident #20's right hip wound. The DON added the Nurse should have sanitized his hands between glove changes. The DON indicated the IP should have recognized that Nurse #2 did not perform the wound treatment per protocol the week prior, and the IP should have educated Nurse #2 on his mistakes.

Based on observation, record review, and interviews with resident and staff, the facility failed to maintain a wheelchair in good repair for 1 of 1 resident reviewed for safe, clean, comfortable and homelike environment (Resident #18). Resident #18 was admitted to the facility on [DATE]. Review of weekly skin assessments from 06/07/25 through 08/09/25 revealed Resident #18's skin was intact. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #18 with moderate impairment in cognition and her primary mobility device was a wheelchair. During an observation conducted on 08/11/25 at 11:30 AM, Resident #18 was seen sitting in her wheelchair next to her bed in her room. The vinyl cover of the left armrest of her wheelchair was in disrepair with multiple torn spots, ripped edges, and cracked lines approximately size of 2.5 inches by 9 inches. Resident #18 was seen wearing a short-sleeved shirt and her left arm was contacting with the broken armrest during the observation. An interview was conducted with Resident #18 on 08/11/25 at 11:32 AM. She stated that she did not know how long the vinyl cover of the left arm rest had been torn, ripped, and cracked and it bothered her as it irritated her skin at times. She added she used the wheelchair frequently and hoped the staff would fix it soon. During a joint observation conducted on 08/12/25 at 10:36 AM with Nurse #4 and Nurse Aide (NA) #2 in the dining room, the vinyl cover of the left armrest of Resident #18's wheelchair remained in disrepair. Resident #18 was sitting in the wheelchair with her left arm contacting the broken armrest. Nurse #4 assessed Resident #18's left arm immediately and reported that her skin was intact without any redness, rashes or open areas. An interview was conducted on 08/12/25 at 10:41 AM with Nurse #4. She acknowledged that she had provided care for Resident #18 frequently in the past few months, but she did not notice the vinyl cover of the left armrest of Resident #18's wheelchair was broken. She added the broken armrest needed to be fixed immediately to ensure Resident #18's skin integrity. During an interview conducted on 08/12/25 at 10:43 AM, NA #2 stated she noticed the vinyl cover of the left armrest of Resident #18's wheelchair was broken and had reported her findings to the Rehabilitation staff a couple weeks ago. However, she could not recall the name of the rehabilitation staff member. She stated the broken armrest needed to be fixed as soon as possible to avoid skin irritation. An interview was conducted on 08/12/25 at 10:48 AM with the Rehabilitation Director. She stated wheelchair repair was typically handled by the maintenance department. The Rehabilitation Director indicated the department depended on nursing staff to report repair needs for wheelchairs. The Rehabilitation Director explained they would address simple repair issues and notify the maintenance department of complicated repair tasks. She denied she had received any reports related to wheelchair repair from nursing staff in the past couple weeks. An interview was conducted on 08/12/25 at 1:17 PM with the Director of Nursing. She expected the staff to be more attentive to residents' mobility devices when providing care and to report repair needs to the maintenance department in a timely manner. It was her expectation for all the mobility devices to be in good repair all the times. During an interview conducted on 08/12/25 at 1:28 PM, the Maintenance Director acknowledged that the vinyl cover of the left armrest for Resident #18's wheelchair was in disrepair and needed to be fixed immediately. He stated the maintenance department did not perform routine walk throughs in the facility to identify repair needs for wheelchairs. Instead, the maintenance department depended heavily on staff to report repair needs via work order clipboard in each nurse station or verbal notification. He typically checked the work order clipboard at least once daily to ensure all the repair needs were addressed in a timely manner. The Maintenance Director stated he did not know the vinyl cover of the left armrest of Resident #18's wheelchair was broken as he never received any report from the staff. He stated it was important for all the staff to be more attentive to residents' mobility devices and report repair needs as indicated when providing care or performing housekeeping. An interview was conducted with the Administrator on 08/13/25 at 12:06 PM. He expected all the staff, including housekeepers and management staff to be more attentive to residents' repair needs and report the findings to maintenance department in a timely manner. It was his expectation for all the mobility devices including wheelchairs to be in good repair all the times.

Based on record reviews and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication, lorazepam (a medication used to relieve anxiety disorder), had a stop date of 14 days for 1 or 5 residents (Resident #3) reviewed for unnecessary medications.Resident #3 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. The care plan for anxiety disorder initiated on 09/22/24 revealed Resident #3 received antianxiety related to anxiety disorder. The goal was to have decreased episodes of anxiety through the next review date. Interventions included administering medications as ordered by the physician. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #3's with severely impaired cognition and indicated she received antianxiety medications during the assessment period. A review of physician's orders dated 07/05/25 revealed Resident #3 had an order to receive one (1) tablet of lorazepam 0.5 milligrams (mg) by mouth once every 4 hours PRN for anxiety disorder. In addition, Resident #3 also had a scheduled order for lorazepam 0.5 mg 4 times daily initiated on 07/05/25. Both orders were entered into the electronic health records by the Medical Director, and there was no stop date for the PRN lorazepam order. A review of Resident #3's July and August 2025 medication administration records (MARs) revealed the PRN lorazepam order that initiated on 07/05/25 remained an active order. Further review of the MARs revealed Resident #3 had not been administered any doses of the PRN lorazepam. An attempt for a phone interview with the Medical Director on 08/12/25 at 12:48 PM was unsuccessful. He did not return the call. During an interview conducted on 08/12/25 at 1:31 PM, Nurse #4 stated she was aware of Resident #3's PRN lorazepam as it remained an active order. She indicated Resident #3 cried frequently in the past and had an order to receive PRN lorazepam 0.5 mg up to 4 times daily. On average, Resident #3 received the PRN lorazepam 2 to 3 times daily in the past. After the physician initiated the scheduled lorazepam 0.5 mg 4 times daily on 07/05/25, the PRN lorazepam had not been administered so far as Resident #3's behavior was under control. Nurse #4 stated she knew all PRN psychotropic drugs were limited to 14 days. Nurses #4 indicated when she saw the PRN lorazepam order for Resident #3 without a stop date, she thought the rules had been changed. An interview was conducted on 08/13/25 at 11:10 AM with the Director of Nursing (DON). She stated it was her expectation for all the physicians to follow the Centers for Medicare and Medicaid Services (CMS) guidelines to set a stop date of 14 days for PRN psychotropic medications. The DON denied this was a system failure but an isolated oversight by the Medical Director and the Consultant Pharmacist. During an interview conducted with the Administrator on 08/13/25 at 12:06 PM, he stated Resident #3's PRN Lorazepam order should have a stop date of 14 days. It was his expectation for all the physicians to follow CMS guidelines when prescribing PRN psychotropic medications.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of bladder and bowel, and medications for 2 of 5 residents (Resident #53 and Resident #21) whose MDS were reviewed.The findings included:1.Resident #53 was admitted to the facility on [DATE].A nursing progress note dated 7/20/25 in Resident #53's medical record indicated the nurse discontinued Resident #53's urinary catheter per order without difficulty and without resident complaint.The admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #53 as having an indwelling catheter and was frequently incontinent of urine.An interview with the MDS Coordinator on 8/13/25 at 10:21 AM revealed she should have coded Resident #53's admission MDS as having no indwelling catheter. The MDS Coordinator stated that Resident #53's urinary incontinence status was auto populated based on responses made by the nurse aides and she was frequently incontinent of urine.An interview with the Director of Nursing on 8/13/25 at 2:05 PM revealed the MDS Coordinator should have coded Resident #53's admission MDS accurately. 2.Resident #21 was admitted to the facility on [DATE].The quarterly MDS dated [DATE] coded Resident #21 as taking anticoagulants. An anticoagulant, also known as a blood thinner, is a medication that helps prevent blood clots from forming or growing larger.A review of the Medication Administration Record for Resident #21 for July 2025 indicated she received Apixaban (an anticoagulant) from 7/1/25 to 7/3/25.An interview with the MDS Coordinator on 8/13/25 at 10:17 AM revealed she didn't see that the Apixaban had been discontinued on 7/3/25 for Resident #21. The MDS Coordinator stated she should not have coded Resident #21 as receiving anticoagulants since she did not receive any anticoagulants during the 7-day look back period from 7/25/25.An interview with the Director of Nursing on 8/13/25 at 2:05 PM revealed the MDS Coordinator should have coded Resident #21's quarterly MDS accurately.

Based on record reviews and interviews with staff and the Consultant Pharmacist, the Consultant Pharmacist failed to identify a drug irregularity and provide recommendations for 1 of 5 residents reviewed for unnecessary medications (Residents #3). Resident #3 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #3's with severely impaired cognition and indicated she received antianxiety medication during the assessment period. A review of physician orders dated 07/05/25 revealed Resident #3 had an order to receive one (1) tablet of lorazepam 0.5 milligrams (mg) by mouth once every 4 hours as needed (PRN) for anxiety disorder. In addition, Resident #3 also had a scheduled order of lorazepam 0.5 mg 4 times daily initiated on 07/05/25. Both orders were entered into the electronic health records by the Medical Director, and there was no stop date for the PRN lorazepam order. A review of Resident #3's July and August 2025 medication administration records (MARs) revealed the PRN lorazepam order that initiated on 07/05/25 remained an active order. Further review of the MARs revealed Resident #3 had not been administered any doses of the PRN lorazepam. A review of Resident #3's medical record revealed the Consultant Pharmacist had conducted a monthly Medication Regimen Review (MRR) on 08/03/25. Further review of Resident #3's August 2025 MMR revealed no recommendations related to the PRN lorazepam order without a stop date had been made by the Consultant Pharmacist to the facility after completing the MRR on 08/03/25. During a phone interview conducted on 08/12/25 at 10:57 AM, the Consultant Pharmacist confirmed he had completed the monthly MRR for Resident #3 on 08/03/25 but he did not recommend the Medical Director to have a stop date for the PRN lorazepam order. He recalled identifying the PRN lorazepam order that originated on 07/05/25 without a stop date but he could not explain why he did not make a recommendation to the physician. He stated he was familiar with the Centers for Medicare and Medicaid Services (CMS) guidelines and indicated the PRN lorazepam order should have a stop date. He attributed the incident to his oversight. An attempt for a phone interview with the Medical Director on 08/12/25 at 12:48 PM was unsuccessful. He did not return the call. During an interview conducted on 08/12/25 at 1:31 PM, Nurse #4 stated she was aware of Resident #3's PRN lorazepam as it remained an active order. She indicated Resident #3 cried frequently in the past and had an order to receive PRN lorazepam 0.5 mg up to 4 times daily. On average, Resident #3 received the PRN lorazepam 2 to 3 times daily in the past. After the physician initiated the scheduled lorazepam 0.5 mg 4 times daily on 07/05/25, the PRN lorazepam had not been administered so far as Resident #3's behavior was under control. During an interview conducted on 08/13/25 at 11:10 AM, the Director of Nursing (DON) stated she expected the Consultant Pharmacist to identify irregularities related to Resident #3's PRN lorazepam when performing monthly MRRs and report the findings to the facility in a timely manner. The DON further stated it was her expectation that the Consultant Pharmacist followed the CMS guidelines when conducting MRRs. An interview was conducted with the Administrator on 08/13/25 at 12:06 PM. He stated Resident #3's physician order for PRN Lorazepam should have a stop date of 14 days. It was his expectation for the Consultant Pharmacist to identify irregularities when performing monthly MRRs and report the findings to the facility in a timely manner.

Based on record review, observations and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions when 3 of 6 staff members (Nurse #2, Nurse #1 and Nurse Aide #1) reviewed for infection control practices failed to wear a gown while performing and assisting with wound care.The findings included: A review of the facility’s undated infection control policy entitled, “Enhanced Barrier Precautions,” indicated enhanced barrier precautions apply when a resident is NOT known to be infected or colonized with any MDRO ([NAME]-drug resistant organism), has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for enhanced barrier precautions (EBP) include dressing, bathing/showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing linens, prolonged, high-contact with items in the resident’s room, with resident’s equipment, or with resident’s clothing or skin, device care or use and wound care (any skin opening requiring a dressing). 1. An observation of wound care on Resident #8 was conducted on 8/12/25 at 1:42 PM with Nurse #2. Nurse #2 was observed performing hand hygiene using hand sanitizer, donned gloves, and removed the dressing from Resident #8’s pressure ulcer to the right buttock. She removed her gloves, applied hand sanitizer to both hands and donned new gloves. She sprayed the wound with wound cleanser, wiped it with dry gauze, removed her gloves and performed hand hygiene using hand sanitizer. She donned new gloves, applied Silvadene cream to the wound and covered it with a foam dressing. She removed her gloves and performed hand hygiene using hand sanitizer. There was no signage for EBP or personal protective equipment outside of Resident #2’s door. An interview with Nurse #2 on 8/12/25 at 1:50 PM revealed Resident #8’s dressing change was scheduled for the evening shift, and it was normally done by the evening shift nurse. Nurse #2 stated she thought the ordered treatment for Resident #8 was just for protection and that the wound was not open which was why she didn’t put on a gown prior to doing the wound care. Nurse #2 stated Resident #8 probably should have been placed on EBP because of her open stage 2 pressure ulcer to the right buttock. An interview with Nurse #3 on 8/12/25 at 3:32 PM revealed she had been doing Resident #8’s treatment on the evening shift since she observed an open pressure ulcer to her right buttock sometime in July 2025. Nurse #3 stated that she was not aware that she had to place Resident #8 on EBP, and that she thought EBP was just for residents with medical devices or active infections. Nurse #3 stated she had never been told by the facility’s Infection Preventionist that EBP was required for residents with open wounds. An interview with the Infection Preventionist (IP) on 8/13/25 at 3:27 PM revealed she was not aware of Resident #8’s pressure ulcer being open. The IP stated she knew Resident #8 used to have a treatment to her buttocks for protection only. The IP stated that Nurse #3 should have initiated EBP for Resident #8 after she identified Resident #8’s pressure ulcer to her right buttock. The IP stated that Nurse #3 received education on EBP, and she was not sure why Nurse #3 was confused except that she might not have understood the education on EBP. The IP further stated that Nurse #2 received education on EBP and should have worn a gown and gloves while providing wound care to Resident #8. An interview with the Director of Nursing (DON) on 8/13/25 at 2:05 PM revealed she was not sure how EBP got missed for Resident #8. The DON stated Resident #8 should have been placed on EBP as soon as her pressure ulcer was identified, and that the nurses should follow EBP and wear a gown and gloves when providing wound care to Resident #8. 2. An observation of wound care on 08/12/25 at 3:10 PM on Resident #50 was conducted with Nurse #1 and Nurse Aide (NA) #1 assisting. Nurse #1 and NA #1 were observed performing hand hygiene, donned gloves, and while NA #1 held the resident over on her side, Nurse #1 removed the dressing from Resident #50’s pressure area to the sacrum. He removed his gloves, washed his hands with soap and water and donned clean gloves. Nurse #1 cleansed the wound with normal saline soaked gauze and dried with another gauze. He doffed his gloves, sanitized his hands and donned new gloves and applied calcium alginate, and covered the wound with foam dressing. Nurse #1 and NA #1 removed their gloves, sanitized their hands, Nurse #1 gathered his supplies and NA #1 gathered the trash and they both left the room. An interview on 08/12/25 at 3:30 PM with NA #1 revealed her understanding of Enhanced Barrier Precautions (EBP) was that she only had to wear a gown while providing incontinence care to Resident #50. An interview on 08/12/25 at 3:40 PM with Nurse #1 revealed he should have worn a gown to perform Resident #50’s wound care. Nurse #1 stated he was in a hurry to get it done and just forgot to put the gown on but said he knew that he was supposed to wear a gown into Resident #50’s room to perform her wound care. An interview on 08/13/25 at 3:20 PM with the Infection Preventionist (IP) revealed Nurse #1 and NA #1 had received education on EBP, and she was not sure why they had not worn a gown in the room because the sign was on the wall beside her door and the bin filled with personal protective equipment (PPE) right outside her door. The IP stated Nurse #1 and NA #1 should have worn a gown while performing wound care to Resident #50. An interview on 08/13/25 at 2:05 PM with the Director of Nursing (DON) revealed she was not sure why Nurse #1 and NA #1 had not worn a gown into Resident #50’s room to do her wound care since she was on EBP. The DON stated the signage was on the wall beside her door and personal protective equipment (PPE) was in a bin right outside her door and there was no excuse for them not wearing a gown while providing wound care to Resident #50.

Based on record review and staff interviews, the facility failed to ensure staff implemented their abuse policy and procedure in the areas of reporting, investigation and protection when nursing staff did not immediately inform the Administrator when a resident reported an allegation of abuse. This failure resulted in a delay in reporting the allegation to the State Agency, local law enforcement and Adult Protective Services (APS) and the facility investigating the allegation for 1 of 3 residents reviewed for abuse (Resident #1). Findings included: The facility's undated policy titled Abuse, Neglect, Exploitation, or Misappropriation of Property - Reporting and Investigating revealed in part, all reports of resident abuse including injuries of unknown origin, neglect, exploitation, or theft/ misappropriation of resident property are reported to local, state and federal agencies as required by current regulations and thoroughly investigated by facility management. Findings of all the investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions if any are needed for the protection of residents. Resident #1 was admitted to the facility on [DATE] and discharged home on 6/27/25. A phone interview on 7/2/25 at 3:10 PM with Nurse Aide (NA) #1 revealed that she worked from 7:00 AM to 11:00 PM on 6/21/25. NA #1 stated that she along with NA #2 were the ones who discovered the bruise on Resident #1's right shoulder during her shower on Saturday 6/21/25 at approximately 11:00 AM. NA #1 stated that she asked Resident #1 what happened. Resident #1 stated that she was hit by a large black woman at night. Resident #1 then stated that she was hit by a lady last week. NA #1 stated that Resident #1 changed her story when NA #1 asked her about the bruise on Resident #1's right shoulder. NA #1 stated that she told Nurse #1 immediately after talking with Resident #1. A phone interview on 7/2/25 at 3:21 PM with NA #2 revealed that she worked from 7:00 AM to 11:00 PM on 6/21/25. NA #2 stated that she and NA #1 were giving Resident #1 a shower and they noticed a bruise on Resident #1's right shoulder. NA #2 asked Resident #1 what had happened. Resident #1 stated that that woman had hit her. She asked Resident #1 what woman? Resident #1 would only say that woman hit her. NA #2 stated that she got Nurse #1 immediately. A phone interview on 7/2/25 at 1:11 PM with Nurse #1 revealed that she worked from 7:00 AM to 7:00 PM on 6/21/25. Nurse #1 stated that Nurse Aide #1 found a bruise on Resident #1's right shoulder during her shower on 6/21/25. Nurse #1 asked Resident #1 what happened. Resident #1 stated that woman hit me. Nurse #1 asked what woman? Resident #1 stated that black lady at night. Nurse #1 stated that she told the Nurse Supervisor immediately after talking with Resident #1. Nurse #1 stated she could not remember if she told the Administrator or the Director of Nursing (DON). She stated that their policy was to report to their immediate supervisors and the Director of Nursing (DON) and file an immediate report. She stated that she should have reported the allegation to the DON since Resident #1 stated that someone had hit her. A phone interview on 7/2/25 at 1:33 PM with the Nurse Supervisor revealed that she worked from 7:00 AM to 7:00 PM on 6/21/25. She stated that Nurse #1 told her about the bruise on Resident #1's right shoulder. She stated that she spoke with Resident #1 on Saturday (6/21/25) and Resident #1 told her that a lady hit her. The Nurse Supervisor stated that she waited a few hours later and Resident #1 told her it was that black girl hit me last week. She stated that Resident #1 had habit of changing her story and giving conflicting information during conversations which was why she waited a few hours to ask Resident #1 about the incident a second time. The Nurse Supervisor stated that she told the DON on Saturday 6/21/25 or Sunday 6/22/25 night, but she did not tell her immediately. She stated that she should have told the DON immediately since Resident #1 stated that she had been hit by someone. A joint interview on 7/2/25 at 4:47 PM with the DON and the Administrator revealed they both expected staff to notify them immediately upon discovery of any abuse allegation. The DON did not recall the Nurse Supervisor telling her about Resident #1's abuse allegation on 6/21/25 or 6/22/25. The DON stated that she would have suspended any suspected staff immediately pending an investigation. The Administrator was notified of the abuse allegation by the surveyor on 7/2/25. The Administrator stated that had he been notified immediately he would have reported the allegation to the state, local law enforcement, and APS within 2 hours. The Administrator stated he would have completed a thorough investigation and provided education to the staff. The DON stated that Nurse #1 and the Nurse Supervisor should have told her about the allegation of abuse immediately.

Based on record review and staff interviews the facility failed to complete a Significant Change in Status Assessment for a resident who had been discharged from hospice care for 1 of 3 residents reviewed for hospice (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes. Review of Resident #3's orders revealed he had been admitted to hospice services on 03/03/21 noting he had a life expectancy of less than 6 months and a diagnosis of heart failure. He was discharged from hospice services on 08/09/23. A phone interview was conducted with the Hospice Provider on 07/02/24 at 3:15 PM. The Hospice Provider revealed Resident #3 had been admitted to hospice services on 03/03/21 through 08/09/21 then switched to hospice palliative care 08/09/21 which was discontinued on 01/08/24. No facility physician orders, or facility documentation were discovered indicating hospice palliative care services had been ordered or discontinued. Review of Resident #3's Minimum Data Sets (MDS) revealed the most recent comprehensive assessment, a Significant Change in Status Assessment, dated 09/28/23, and followed by three quarterly assessments dated 12/27/23, 03/27/24, and 06/24/24. These assessments were coded for receiving hospice care. An interview conducted with the MDS Coordinator on 07/03/24 at 12:35 PM revealed it was not communicated to her that Resident #3 had been discharged from hospice and palliative care on 01/08/24. She indicated she usually got her information regarding hospice discharges through the nurses and review of the resident's chart. The MDS Coordinator stated a significant change in status assessment had been completed in September because Resident #3 had a fall with an injury. The MDS Coordinator indicated a significant change in status assessment should have been completed for Resident #3 when the hospice services ended. An interview conducted with the Administrator and Director of Nursing (DON) on 07/03/24 at 1:30 PM revealed they were not aware Resident #3 had been discharged from hospice and palliative care services. It was further revealed they expected the MDS assessments to be coded accurately and was not aware a significant change in status assessment had not been completed when Resident #3 was discharged from hospice services.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment for 3 of 6 residents reviewed for hospice, discharge, and falls (Resident #3, Resident #40, and Resident #50). Findings included: 1. Resident #3 was admitted to the facility on [DATE] with diagnoses including heart failure and depression. Review of Resident #3's orders revealed he had been admitted to hospice services on 03/03/21 noting he had a life expectancy of less than 6 months and a diagnosis of heart failure. He was discharged from hospice services on 08/09/23. A phone interview was conducted with the Hospice Provider on 07/02/24 at 3:15 PM. The Hospice Provider revealed Resident #3 had been admitted to hospice services on 03/03/21 through 08/09/21 then switched to hospice palliative care 08/09/21 which was discontinued on 01/08/24. No facility physician orders, or facility documentation were discovered indicating hospice palliative care services had been ordered on 08/09/23 or discontinued on 01/08/24. Review of Resident #3's quarterly Minimum Data Sets (MDS) dated [DATE], and 06/24/24 revealed the resident was coded for receiving hospice care. An interview conducted with the MDS Coordinator on 07/03/24 at 12:35 PM revealed it was not communicated to her that Resident #3 had been discharged from hospice and palliative care on 01/08/24. She indicated she usually got her information regarding hospice discharges through the nurses and review of the resident ' s chart. The MDS Coordinator further revealed Resident #3 should have not been coded for hospice care on the quarterly MDS assessments for 03/27/24 and 06/24/24. An interview conducted with the Administrator and Director of Nursing (DON) on 07/03/24 at 1:30 PM revealed they were not aware Resident #3 had been discharged from hospice and palliative care services. It was further revealed they expected the MDS assessments to be coded accurately. 45380 2. Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis included dementia and falls. Review of Resident #40 progress note dated 5/29/24 revealed Resident #40 was readmitted from the hospital on 5/24/24 due to a fall with injury at the facility. Resident #40 readmission diagnosis on 5/29/24 included fracture of neck, not operable, due to fall. Review of 5-day admission Minimum Data Set (MDS) assessment dated [DATE] revealed no history of falls or falls with major injury. An interview with the MDS Coordinator on 7/03/24 at 1:18 PM revealed Resident #40 had been readmitted to the facility from the hospital on 5/29/24 due to a fall with major injury. She stated Resident #40 should have been coded on his 5-day admission assessment dated [DATE] as having a history of falls and one fall with major injury. She revealed she believed it was just an oversight and human error on her part that she forgot to check the correct boxes under falls. An interview with the Director of Nursing (DON) on 7/03/24 at 1:31 PM revealed Resident #40 5-day admission MDS dated [DATE] should have reflected his previous fall with major injury. She stated MDS assessments should be coded correctly and reflect resident's current orders, changes in conditions, incidents, assessments, and status. 3. Resident # 50 was admitted to the facility on [DATE] and was discharged home on 4/05/24. Review of Resident #50 discharge progress note dated 4/05/24 revealed Resident #50 to discharge home with home health referral completed to evaluate and treat in home and ordered medical equipment received and available at resident home. Resident #50 was wheeled to vehicle and assisted into front seat and her belongings were taken by her husband. Discharge instructions were verbally reviewed in detail with Resident #50 husband, he verbalized understanding, and a written copy was provided. Resident #50 prescriptions were faxed to pharmacy with confirmation received, follow-up appointment made with primary care physician for 4/16/24 at 2:40 PM. Resident #50 had left facility with husband in pleasant mood. The discharge Minimum Data Set (MDS) assessment dated [DATE] indicated under the discharge status, that Resident #50 was an unplanned, return not anticipated discharge to home. An interview with the MDS Coordinator on 7/03/24 at 1:25 PM revealed Resident #50 was a planned discharge and should have been coded as a planned, return not anticipated, discharge to home. She stated she believed it was just an oversight and human error on her part that she forgot to check the correct box under discharge status. An interview with the Director of Nursing on 7/03/24 at 1:40 PM revealed Resident #50 discharge was planned, and she should have been coded on her discharge MDS assessment as a planned discharge to home. She stated MDS assessments should be coded correctly and reflect resident's current orders, changes in condition, admission, and discharge status.

Based on staff interviews and record review, the facility failed to develop personalized comprehensive care plans in the areas of anticoagulation therapy, diuretic therapy, insulin, psychotropic drugs, depression, use of indwelling urinary catheter and respiratory therapy for 2 of 5 residents reviewed (Resident #21, #2). The findings include: 1. Resident #21 was admitted to the facility on [DATE] with a history of deep vein thrombosis (DVT) with pulmonary embolism, diabetes mellitus (DM) type 2, hypertension (HTN), benign prostatic hypertrophy (BPH) with urinary retention, and history of urinary tract infections (UTI), chronic kidney disease. Resident #21's care plan dated 12/08/2022 revealed there was no care plan in place for anticoagulant medication, insulin, or diuretic medication and after 1/26/2023 for indwelling urinary catheter. A review of the most recent Minimum Data Set (MDS) assessment for discharge date d 1/23/2023 revealed Resident #21 independent with decision making and required extensive assistance with bed mobility, transfers, and toilet use. He was frequently incontinent of both bowel and bladder. He returned to the facility from hospital on 1/26/2023. Review of Physician orders dated 01/26/2023 revealed Apixaban 5 mg (an anticoagulant) twice a day. Furosemide (a diuretic) 40 mg daily and insulin 18 units at night. Review of Physician's order dated 01/26/2023 indicated to replace indwelling urinary catheter every 4 weeks and provide catheter care every shift. Interview with MDS Coordinator on 03/02/2023 at 03:30PM revealed she was aware Resident #21 received insulin, anticoagulant and diuretic. She revealed that the anticoagulant and insulin were usually care planned. Diuretics were not usually care planned unless a resident had history of dehydration. She reported the care plans were missed because, Resident #21 was and out of facility and system software did not trigger her to care plan. An interview was conducted on 03/03/23 at 11:20 AM the Director of Nursing (DON) stated she expected to see appliances such as catheters, on a resident care plan and expected to see interventions in place. She stated that care was communicated through conversation. 47683 2. Resident #2 was admitted to the facility on [DATE] with a diagnosis that included anxiety, dementia, Chronic Obstructive Pulmonary Disease (COPD), and psychosis. A review Resident # 2's physician orders revealed on 1/28/22 she was prescribed DuoNeb one treatment every 4 hours as needed for COPD. On 5/30/22 she was prescribed Zoloft 100 mg tablet by mouth daily for depression. On 11/28/22 she was prescribed Geodon 20 milligrams (mg) capsules take one capsule every morning oral every day and Geodon 40 mg by mouth everyday with supper (must be taken with meal) for psychosis. On 2/28/23 she was prescribed Ativan 0.5 mg tablet to take 1/2 tablet (0.25mg) by mouth every 8 hours as needed for agitation for 14 days for anxiety. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #2 was severely cognitively impaired. Resident # 2 was coded for diagnoses of depression, psychotic disorder, COPD, delusional disorder and was on oxygen through a nasal canula. Review of Resident #2's comprehensive care plan dated 2/27/23 revealed there were no care plans in the areas of COPD, or psychosis. An interview with the MDS Coordinator on 3/2/23 at 12:10 PM indicated Resident #2 had received medications that required monitoring. Resident #2 had received medications for psychosis, anxiety, COPD, and depression. Resident #2 was on Geodon for psychosis and was placed on Geodon after having delusions in November 2022. The MDS Coordinator indicated she should have care planned Resident #2's diagnosis of COPD with the use of the DuoNeb medication and the resident's psychotic disorder with the treatment of an antipsychotic medication. She stated the resident was not care planned for anxiety and depression because she had not exhibited behaviors. An interview with Director of Nursing (DON) on 03/03/23 at 1:26 PM revealed that there should have a care plan with diagnoses and medications that require monitoring.

Based on observation, staff and resident interview, and record review, the facility failed to ensure dependent residents received assistance with nail care for 2 of 3 residents reviewed for activities of daily living (ADL). (Residents #8 and #15) The findings included: 1.Resident #8 was admitted to the facility on [DATE] with diagnosis of heart failure, atrial fibrillation, congestive obstructive pulmonary disease (COPD), and contracture of right hand. Resident #8's care plan dated 1/21/2022 included a care plan for ADL care. Intervention included to assist with ADLs as needed. Resident #8's annual Minimum Data Set (MDS) dated [DATE] revealed she was coded as cognitively intact. She required extensive assistance with personal hygiene. Resident #8 was dependent upon staff for bathing and grooming. No refusals of care were coded on the MDS. On 3/01/2023 at 10:21 AM, an observation and interview with Resident #8, revealed she was lying in bed and her fingernails on the left hand were observed to be jagged and approximately 1/4 inch past the tip of her fingers. Resident #8's thumb nail and index fingernails on the right hand were approximately 1/2 inch past the fingertip. Resident #8's fingernails were noted to be dark in color. She had a rolled washcloth in the right hand. Resident #8 reported the washcloth was there because she was not able to open her hand. Resident #8 reported she had asked staff to trim her nails, but they had not been cut. She was not able to remember the last time her nails had been trimmed but did say that her nails were usually trimmed during her shower. Resident #8 reported having a shower earlier in the week, but she could not recall the exact day. Resident #8 reported her fingernails had not been trimmed during her last shower. An interview with NA #1 on 03/02/2023 at 09:48 AM was completed. She revealed fingernails were cut on bath day. NA #1 reported that the Activities Director (AD) also did nail care. Resident #8 was observed sitting in her wheelchair on 03/02/2023 at 09:51 AM. Her fingernails to both hands remained jagged and the same length as the previous day. Resident #8 reported her bath was scheduled for Friday (03/03/2023). Review of care aid papers for the week of 02/28/2023 - 03/05/2023 showed Resident #8 was scheduled for showers on Tuesdays and Fridays. Review of the progress notes for Resident #8 dated 02/28/2022 - 03/03/2023 showed no documentation of refusal of care to include nail care. During an interview with Nurse #1 on 03/02/2023 at 10:26 AM she reported the AD usually trimmed fingernails unless the resident was diabetic then the nurse would do it. Nurse #1 continued to verbalize that NA's were also responsible for nail care. Nurse #1 reported nails should be cleaned during bath time. 2.Resident #15 was admitted to the facility on [DATE] with diagnosis of hypertension and atrial fibrillation. Resident #15's care plan dated 11/30/2022 included a care plan for ADL care. Interventions included assist with ADLs as needed. Resident #15's significant change MDS dated [DATE] revealed Resident #15 was cognitively intact and required extensive assistance with personal hygiene and bathing. During review of MDS no episodes of refusing care was coded. On 3/01/2023 at 11:07 AM Resident #15 was observed sitting in her wheelchair in her room. An observation was completed of her fingernails on both hands. Her nails were observed to be approximately 1/4 inch past the fingertip. Resident #15's nails to the left hand were jagged and chipped. Resident #15 reported she preferred to have her nails short. Resident #15 reported her nails were trimmed during her shower and she received showers twice a week. She could not recall the last time her nails had been trimmed. Resident #15 said she had a shower this week but could not recall which day. An observation of Resident #15 on 3/02/2023 at 09:43 AM revealed fingernails on bilateral hands were still the same length as the previous day. There was brown matter noted underneath the thumb and index finger of the right hand. An interview with Nurse Aide (NA) #1 on 3/02/2023 at 09:48 AM revealed Resident #15's fingernails were cut on bath day, NA #1 reported that Activities Director (AD) also did nail care. During an interview with Nurse #1 on 3/02/2023 at 10:26 AM indicated that the nurses trimmed the diabetic resident nails, and the AD and NA trimmed the rest of the nails. Nurse #1 reported nails were cleaned during bath time. Review of care aid papers for the week of 2/28/2023 through 3/05/2023 showed Resident #15 was scheduled for showers on Monday and Thursday on second shift. An observation of Resident #15 on 03/03/2023 at 08:55 AM showed nails on both hands were still approximately 1/4 inch past the fingertips. Resident #15 reported her shower was moved from Thursday to the following Monday. Resident #15 had no concerns about having to move her shower from Thursday to Monday. Review of nurse's notes dated 02/28/2023 - 03/03/2023 revealed no episodes of refusal of care to include nail care had been documented. During interview with Activities Director (AD) on 03/03/2023 at 08:58 AM she reported nail care, as an activity was performed on Thursdays. Nails were polished, trimmed, and filed. She went down the different halls to find out if any residents were interested. The AD stated the nurse on the hall or the NA asked the AD to look at resident's nails and if they needed to be trimmed or cleaned, she would do it. Interview on 03/03/2023 at 09:24 AM with NA #2, who was responsible for the care of Resident's #8 and #15 revealed that during baths and daily care, fingernails and toenails were trimmed and cleaned. She indicated nail care was completed in the resident room, and not only on the shower days. NA #2 reported nail care was not completed because it was not high priority. During an observation NA #2 acknowledged that the fingernails required cleaning and trimming. An interview on 03/03/2023 at 11:20 AM with Director of Nursing (DON) revealed nail care was completed on bath or shower day and as needed. The DON reported the AD had a nail activity usually weekly and it was up to the nursing staff to make sure nails were cleaned and trimmed.

Based on observation, record review, staff and Pharmacy interview the facility failed to label and date medications for 1 of 2 storage rooms reviewed for medication storage and labeling. The findings include: During an observation on 03/02/23 at 11:45 AM with Nurse #2 of medication room # 1 revealed an unlabeled plastic bag with 4 unidentified white pills found in an unlocked cabinet inside locked medication room # 1. An interview with Nurse # 2 on 03/02/23 at 11:46 AM indicated that she was unaware of what the 4 pills were in the plastic bag. She further indicated that the plastic bag with the 4 white pills should have been labeled with the type of medication, time due, and name of resident. Nurse # 2 revealed that nursing was responsible for the stocking and checking expiration dates for medications stored in the medication room cabinets. Continued observation in medication room # 1 on 3/02/23 at 11:47 AM revealed 10 prepackaged pills found in the same unlocked cabinet as the plastic bag with 4 unidentified white pills for a resident dated for administration of 12/18/22 and 12/19/22 with no indicated expiration date noted. The prepackaged pills were identified as 1 Metoprolol 25 milligram (MG) tablet, 1 Omeprazole capsule 20 MG, 1 Memantine 10 MG, 1 Buspirone 5 MG tablet, 1 DOK 100 MG tablet, 1 Vitamin D3 25 MG tablet, 1 Sertraline tablet 50 MG, and 3 Furosemide 20 MG tablet. An interview with Nurse # 2 on 03/02/23 at 11:48 AM indicated there should be a clear expiration date on the prepackaged pills. She further indicated the facility doesn't have packaging like that, and it probably came from a hospital. A phone interview with the Pharmacy on 3/3/23 indicated they don't look in the cabinets in the medication rooms. Medications were delivered to the nurses, and they were responsible for storage and management of expirations dates. An interview with the Director of Nursing (DON) 03/03/23 at 1:32 PM revealed the plastic bag with white pills should have been discarded. The prepackaged pills should have been sent home with the resident's family. She was unsure why they were left in the cabinet in medication room # 1.

Based on observation, record review, resident, family, and staff interviews the facility imposed a restricted visitation schedule that limited indoor and outdoor visitation of family and friends for 4 of 38 residents reviewed for visitation. (Resident #5, #20, #26 and #39). This facility practice had the potential to affect all residents. Findings included: 1. Resident #26 was admitted to the facility on [DATE] and was coded as being cognitively intact. Interview with Resident #26 who was cognitively intact on 8/31/21 at 3:13pm revealed her family could not come into the facility to visit. She stated they were only allowed to come to the window and they couldn't visit after 4:00pm. Observation at 8/30/21 at 3:35pm revealed Resident #26 to be visiting outside with her family member. Interview with Resident #26 family member on 8/30/31 at 3:36pm revealed she was unable to visit with Resident #26 the previous week at all. She stated this week she was able to schedule an appointment to visit through the window. She further stated when the family arrived today they were told by the facility that they could visit Resident #26 outside. The facility allowed an hour of visitation. Before the previous week the facility allowed visitation every other day. 2. Resident #39 was admitted to the facility on [DATE] and was coded as being cognitively impaired. Interview and observation on 8/31/21 at 3:45pm revealed Resident #39 to be visiting with her family members outside the facility. The family indicated they had to make appointments to see Resident #39. They indicated it could be difficult to schedule due to family members work schedules. They stated in the instance a family member got off work at 5:00pm they wouldn't be able to visit. They stated they couldn't visit at all last week. The family was told a facility staff had gotten COVID and they weren't letting anyone in. 3. Resident #5 was admitted to the facility on [DATE] and was coded as cognitively impaired. An interview was conducted with Resident #5's family member on 09/01/21 at 10:45 AM. The family member stated they cannot visit with their mother during the restricted visitation hours. They indicated visitation hours were from 9:00 AM to 4:30 PM during the day. The family member worked during the day and would have to take time off work to visit with their mother. They revealed visitation hours were restricted to 1-hour increments and they could make an appointment for Tuesday, Wednesday, or Thursday during the week. The family member stated there were no evening visitation hours. They further indicated window visits and outside visits occurred on the weekends. The family member revealed they were unable to sit in the heat for the duration of outside visits. They stated there were 2 spots available for visitation at a time. 4. Resident #20 was admitted to the facility on [DATE] and was coded as being cognitively intact. In an interview with Resident #20 on 09/03/21 at 9:05 AM, the resident expressed she wanted the facility to allow visitors on the weekends, and she had not received visitors in 2 weeks. The resident revealed she could have 2 visits a week but the visits must be scheduled ahead of time. She stated her preacher could not get a pass to visit and she believed the preacher should be able to visit any time he wanted. She stated her family worked during the day and could only come after 3:30 PM. She wanted her family to be able to visit at any time they could. Interview with the Receptionist on 9/2/21 at 3:12pm revealed the facility suggested outside visitation. They were allowing families to come in the facility but the facility were going with CDC guidelines that say it is safer outside. She stated if families asked they could come in. The time frames for visits were 9:00am to 10:00am, 11:00am then a break. Visitation resumed at 1:30pm, 2:30pm and 3:30pm. The last time a visit could be scheduled was 3:30pm. If a slot for visitation was taken when a family called to schedule a visit, we would try to fit them in. She stated if the family called and ask to visit because they worked late someone would stay at the facility to check the family in. Some families complained but the facility always tried to make it work. She stated the she was responsible for scheduling the visits. The receptionist revealed weekend visits were scheduled at 1:30pm, 2:30pm and 3:30pm. She stated she kept a log of the visits. Residents with private rooms could get visit inside but semi-private private rooms had to be conducted outside or in the 300 hall living room. Interview with the Director of Nursing (DON) on 9/2/21 at 9:26am revealed she was recommending outside visits at this time. The CDC said it was the safest way due to having open air. Prior to the outbreak they were allowing families to come into the facility. The outbreak started on 7/30/21 and the second was 8/23/21. Visits were scheduled and had time frames which was 7 days a week and started at 9:00am. The visits were from 9:00am to 11:00am and 1:00pm until 4:00pm. She stated they always had compassionate care visits or visits for end of life. If families demanded to come in the facility, the facility allowed them to come in. The facility would usually try to educate the families about the policy and they are usually more compliant. The receptionist scheduled the visitation and it is up to her discretion. Interview with the Administrator on 9/2/21 at 10:15am revealed if a family member wanted to come in the building they would be allowed to. The facility had exceptions to the scheduled visits and compassionate visits were anytime. Outside visitation was suggested to prevent outbreaks.

Based on observations and staff interviews, the facility failed to ensure the medication storage rooms were locked for 2 of 2 medication storage rooms (200 hall and the central medication storage room) reviewed for medication storage. The findings included: a. A continuous observation of the 200-hall medication storage room on 9/1/2021 from 10:25 AM to 10:41 AM revealed Nurse #1 left the medication storage room door propped open with a trash can. During the continuous observation Nurse #1 went to the restroom and then walked down the 200 hall before she came back to the medication storage room to close the door. During the observation, no one other than Nurse #1 entered the medication storage room. An interview with Nurse #1 on 9/1/2021 at 10:47 AM revealed the 200 hall medication storage room door should not have been left open. b. During an observation and interview on 9/1/2021 at 10:57 AM Nurse #2 was observed to get her keys out of her pocket to unlock the central medication storage room door. The medication storage room door was observed to be unlocked as the nurse only had to push on the door to open it without unlocking it with her keys. Nurse #2 explained the central medication storage room door sometimes did not close correctly, but it was normally locked. Nurse #2 indicated that she did not know whether maintenance had been notified of the door not closing correctly. She further revealed that she intended to notify maintenance. During an interview with the Director of Nursing on 9/2/2021 at 9:44 AM she stated the 200 hall medication storage room door should not have been left unlocked and propped open with a trash can. She further stated the central medication storage room door should have been locked and the nurses should have made sure the door was shut completely An interview with the Administrator on 9/2/2021 at 10:20 AM revealed both medication storage room doors should be locked at all times. The Administrator revealed the issue concerning the central medication storage room door was not reported because there was nothing wrong with the door.

Based on record review, staff, consultant pharmacist, physician assistant, and physician interviews the facility failed to address the use of as needed (PRN) [MEDICAL CONDITION] (drug that affects mental state) for 4 of 7 residents reviewed for unnecessary medication (Resident #6, #5, #23, and #17). Findings included: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #6 was cognitively intact. Resident #6 received hypnotic (sleep) medication on 7 of 7 days. A physician's assistant order dated 07/09/18 [MEDICATION NAME]([MEDICAL CONDITION] medication for sleep) 5 milligram (mg) by mouth at bedtime PRN for sleep was ordered for Resident #6. There was no 14 day stop date for the [MEDICATION NAME]. A review of the Medication Administration Record [REDACTED]. The consultant pharmacist (CP) monthly drug regimen review for Resident #6 indicated the CP had not recommended on 08/07/18, 09/07/18, 10/05/18, 11/05/18, 12/06/18, 01/07/19, 02/07/19, and 03/07/19 to the physician that a 14 day stop date for [MEDICATION NAME] required unless a clinical justification was provided for continuing [MEDICATION NAME] than 14 days. On 03/26/19 at 12:46 PM a telephone interview was conducted with the physician who stated he was aware of the regulation that indicated PRN [MEDICAL CONDITION] medication required a 14 day duration unless he reevaluated Resident #6 and documented justification for continued need beyond 14 days and stated he had not provided a stop date or provided justification for continued use of PRN Ambien. The physician stated he had not received communication from the consultant pharmacist to consider reevaluation of Resident #6 for the justification of continued needs of [MEDICATION NAME] 14 days. On 03/26/19 at 3:55 PM a telephone interview was conducted with the CP who stated PRN [MEDICAL CONDITION] medication was limited to 14 days unless the prescriber provided a justification to extend the order past 14 days. The CP stated he must have missed notifying the practitioner of the 14 day limitation for Resident #6's [MEDICATION NAME] unless the practitioner provided justification to extend the order past 14 days. The CP stated it was his expectation that the practitioner would have reevaluated Resident #6 after 14 days and provided documentation of justification of continued needs for PRN Ambien. On 03/27/19 at 10:53 AM an interview was conducted with the physician assistant (PA) who stated he was not aware of the Centers of Medicare & Medicaid Services (CMS) [MEDICAL CONDITION] medication regulation regarding PRN [MEDICAL CONDITION] medication that required a 14 day stop date or justification of continued need beyond 14 days for the use of PRN Ambien. The PA stated he had not provided a stop date for Resident #6's PRN Ambien. The PA indicated he had not reevaluated Resident #6's continued need for [MEDICATION NAME] 14 days and had not provided a justification for the continued use of PRN Ambien. The PA stated he did not remember receiving a recommendation from the CP for him or the physician to review the continued need for [MEDICATION NAME] 14 days or provide justification for continued need beyond 14 days for Resident #6. On 03/27/19 at 11:20 AM an interview was conducted with the Director of Nursing (DON) who stated she had not received a recommendation from the CP for the physician to review the continued need for [MEDICATION NAME] 14 days for Resident #6. On 03/27/19 at 11:47 AM an interview was conducted with the Administrator who stated it was his expectation that the CP who reviewed Resident #6's medication regimen monthly to have recommended that the physician evaluate the continued need for [MEDICATION NAME] 14 days for Resident #6 or provide justification for continued need per CMS regulation. 2. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was severely cognitively impaired. Resident #5 did not receive anti-anxiety medication during the assessment period. Review of the physician's orders [REDACTED].#5. There was no 14 day stop date written for the prn [MEDICATION NAME] order. A review of the Medication Administration Record [REDACTED]. Review of the MAR further revealed Resident #5 received one dose of prn [MEDICATION NAME] in October, 8 doses in November, 13 doses in (MONTH) of (YEAR). Resident #5 received 13 doses in January, none in February, and 1 dose in (MONTH) of 2019. Review of the Consultant Pharmacist (CP) monthly drug regimen for Resident #5 revealed the CP had not recommended on 5/7/18, 6/7/18, 7/7/18, 8/7/18, 9/7/18, 10/5/18, 11/5/18, 12/6/18 and 1/7/19, 2/7/19, 3/7/19 to the physician that a 14 day stop date for prn [MEDICATION NAME] was required unless a clinical justification was provided for continuing prn [MEDICATION NAME] greater than 14 days. On 03/26/19 at 12:46 PM a telephone interview was conducted with the physician who stated he was aware of the regulation that prn [MEDICAL CONDITION] medication required a reason to be prescribed longer than a 14 day duration. He stated he had not reevaluated Resident #5 for continued need of prn [MEDICATION NAME] beyond 14 days nor had he provided a stop date or provided justification for continued use of prn [MEDICATION NAME]. The physician stated to his knowledge he had not received communication from the CP to consider reevaluation of Resident #5 for the justification of continued needs of prn [MEDICATION NAME] beyond 14 days. On 03/26/19 at 3:55 PM a telephone interview was conducted with the CP who stated prn [MEDICAL CONDITION] medication was limited to 14 days unless the prescriber provided a justification to extend the order past 14 days. The CP stated he must have missed notifying the practitioner of the 14 day limitation for Resident #5's prn [MEDICATION NAME] order unless the practitioner provided justification to extend the order past 14 days. The CP stated it was his expectation that the practitioner would have reevaluated Resident #5 after 14 days and provided documentation of justification of continued needs to continue prn [MEDICATION NAME]. On 03/27/19 at 2:45 PM an interview was conducted with the Director of Nursing (DON) who stated she had not received a recommendation from the CP to review the continued need for prn [MEDICATION NAME] beyond 14 days for Resident #5. On 03/27/19 at 4:30 PM an interview was conducted with the Administrator who stated it was his expectation that the CP who reviewed Resident #5's medication regimen monthly to have recommended that the physician evaluate the continued need for prn [MEDICATION NAME] beyond 14 days for Resident #5 or provide justification for continued need per CMS regulation. 3. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #23 was severely cognitively impaired. Resident #23 did not receive the anti-anxiety medication during the assessment period. A physician's orders [REDACTED].½ tablet by mouth twice a day as needed (prn) for anxiety was ordered for Resident #23. There was no 14 day stop date written for the prn [MEDICATION NAME] order. A review of the Medication Administration Record [REDACTED]. Review of the MAR further revealed the resident received 1 dose of prn [MEDICATION NAME] in January, 3 doses in February, and 2 doses in (MONTH) of 2019. The Consultant Pharmacist (CP) monthly drug regimen review for Resident #23 indicated the CP had not recommended on 5/7/18, 6/7/18, 7/7/18, 8/7/18, 9/7/18, 10/5/18, 11/5/18, 12/6/18 and 1/7/19, 2/7/19, 3/7/19 to the physician that a 14 day stop date for prn [MEDICATION NAME] was required unless a clinical justification was provided for continuing prn [MEDICATION NAME] greater than 14 days. On 03/26/19 at 12:46 PM a telephone interview was conducted with the physician who stated he was aware of the regulation that prn [MEDICAL CONDITION] medication required a reason to be prescribed longer than a 14 day duration. He stated he had not reevaluated Resident #23 for continued need of prn [MEDICATION NAME] beyond 14 days nor had he provided a stop date or provided justification for continued use of prn [MEDICATION NAME]. The physician stated to his knowledge he had not received communication from the CP to consider reevaluation of Resident #23 for the justification of continued needs of prn [MEDICATION NAME] beyond 14 days. On 03/26/19 at 3:55 PM a telephone interview was conducted with the CP who stated prn [MEDICAL CONDITION] medication was limited to 14 days unless the prescriber provided a justification to extend the order past 14 days. The CP stated he must have missed notifying the practitioner of the 14 day limitation for Resident #23's prn [MEDICATION NAME] order unless the practitioner provided justification to extend the order past 14 days. The CP stated it was his expectation that the practitioner would have reevaluated Resident #23 after 14 days and provided documentation of justification of continued needs to continue prn [MEDICATION NAME]. On 03/27/19 at 2:45 PM an interview was conducted with the Director of Nursing (DON) who stated she had not received a recommendation from the CP to review the prn [MEDICATION NAME] for continued need beyond 14 days for Resident #23. On 03/27/19 at 4:30 PM an interview was conducted with the Administrator who stated it was his expectation that the CP who reviewed Resident #23's medication regimen monthly to have recommended that the physician evaluate the continued need for prn [MEDICATION NAME] beyond 14 days for Resident #23 or provide justification for continued need per CMS regulation. 4. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #17 was cognitively intact. Resident #17 did not receive the anti-anxiety medication during the look back period. A physician's orders [REDACTED].#17. There was no 14 day stop date written for the prn [MEDICATION NAME] order. A review of the Medication Administration Record [REDACTED]. The Consultant Pharmacist (CP) monthly drug regimen review for Resident #17 indicated the CP had not recommended on 3/7/19 to the physician that a 14 day stop date for prn [MEDICATION NAME] was required unless a clinical justification was provided for continuing prn [MEDICATION NAME] greater than 14 days On 03/26/19 at 12:46 PM a telephone interview was conducted with the physician who stated he was aware of the regulation that prn [MEDICAL CONDITION] medication required a reason to be prescribed longer than a 14 day duration. He stated he had not reevaluated Resident #17 for continued need of prn [MEDICATION NAME] beyond 14 days nor had he provided a stop date or provided justification for continued use of prn [MEDICATION NAME]. The physician stated to his knowledge he had not received communication from the CP to consider reevaluation of Resident #17 for the justification of continued needs of prn [MEDICATION NAME] beyond 14 days. On 03/26/19 at 3:55 PM a telephone interview was conducted with the CP who stated prn [MEDICAL CONDITION] medication was limited to 14 days unless the prescriber provided a justification to extend the order past 14 days. The CP stated he must have missed notifying the practitioner of the 14 day limitation for Resident #17's prn [MEDICATION NAME] order unless the practitioner provided justification to extend the order past 14 days. The CP stated it was his expectation that the practitioner would have reevaluated Resident #17 after 14 days and provided documentation of justification of continued needs to continue prn [MEDICATION NAME]. On 03/27/19 at 2:45 PM an interview was conducted with the DON who stated she had not received a recommendation from the CP to review the prn [MEDICATION NAME] for continued need beyond 14 days. On 03/27/19 at 4:30 PM an interview was conducted with the Administrator who stated it was his expectation was that the CP who reviewed Resident #17's medication regimen monthly to have recommended that the physician evaluate the continued need for prn [MEDICATION NAME] beyond 14 days for Resident #17 or provide justification for continued need per CMS regulation.