Circle Of Care

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that resident representatives were notified of significant changes in condition, as required by both facility policy and the Nursing Home Residents' Rights. In the case of one resident with multiple complex medical diagnoses, including sepsis, paraplegia, and end stage renal disease, there were two separate hospital transfers due to acute changes in condition. Documentation showed that the resident's mother, who was the designated representative, was not notified of either transfer. This was confirmed by both the resident and the mother, who expressed distress at not being informed. Nursing staff interviews confirmed that it was their responsibility to notify family or representatives, but there was no documentation of such notifications for these events. Another resident, with diagnoses including diabetes insipidus, traumatic brain injury, neurocognitive disorder, and cancer, was transferred to the hospital after removing sutures from a surgical site, resulting in bleeding. This resident had a legal guardian, as documented in the medical record. However, there was no evidence that the guardian was notified of the incident or the subsequent hospital transfer. The guardian reported only learning of the transfer when contacted by the hospital for necessary paperwork. Nursing staff again confirmed their responsibility to notify representatives, but no documentation of notification was found. Review of facility policy and residents' rights documents indicated that representatives should be informed of significant changes in health status, including hospital transfers, as soon as possible or within 12 hours. Despite these requirements, the facility did not document or provide evidence of timely notification to the appropriate representatives in these cases, resulting in a deficiency related to communication and notification of significant changes.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria in the water supply. Despite receiving water test results indicating elevated and increasing levels of legionella, the facility did not re-evaluate or update its water management risk assessment or plan, nor did it provide effective interventions to mitigate the risk. The facility also did not ensure that residents were prevented from accessing or using water from areas where legionella could be present, as evidenced by residents continuing to use sinks and showers in affected areas without appropriate filters or signage restricting use. The facility's water management risk assessment was outdated and lacked critical components such as summaries, acceptable control levels, and response procedures for positive legionella findings. Maintenance activities were inconsistently documented, with no evidence of routine maintenance or cleaning of showers, whirlpools, or flushing of water in unoccupied rooms as required. Water testing was limited to a single location, and when results showed a significant increase in legionella levels, there was no documented investigation or intervention. Staff interviews confirmed a lack of awareness of the severity of the test results, and there was no evidence that residents were assessed for symptoms of Legionnaires' Disease during the period of elevated risk, including those with respiratory symptoms or hospitalizations. Residents, including those with high-risk conditions such as tracheostomies, ventilator dependence, and those receiving dialysis, continued to use water sources that were potentially contaminated. Interviews with residents confirmed ongoing use of sinks and showers in areas where legionella was present, and staff confirmed that there were no effective restrictions or visual cues to prevent such use. The facility's infection surveillance system was also found to be ineffective, as it failed to track infections and monitor trends, and appropriate infection control techniques were not followed during wound care for at least one resident.

Removal Plan

• An all-staff in-service was completed on risks, signs and symptoms and interventions for legionella by the DON and IP Nurse #302.
• Water to each sink in all facility rooms was shut off to prevent accidental use by residents and staff. Gallon jugs of purified water were put in place to wash hands with dates and names on each.
• The DON/designee would audit employee call-offs weekly, monitoring for any symptoms related to legionella illness. Any concerns would be immediately reported to the Administrator and addressed by the Quality Assessment Performance Improvement (QAPI) committee as necessary.
• The facility contracted with PT enterprises to assist with the water management plan. PT enterprises took twelve water samples (four swabs and eight additional 250 ml potable water samples).
• Point of use filters for all water sources in the facility were ordered.
• The DON brought in hot and cold-water dispensers for use on the second and third floors. This water was provided for residents' use for any residents who did not want to drink bottled water and staff were responsible for bringing the water to residents. Additional bottled water was supplied to the fourth floor.
• The DON educated the weekend staff and agency staff working on-site on not using the room sinks or shower on the second floor, as well as signs and symptoms of legionella.
• A Legionella assessment data collection form was created in point click care (PCC), which included a set of vital signs, a review of potential symptoms of legionella, a place for a narrative, and a yes or no question as to whether or not the resident experienced more than three symptoms beyond their baseline.
• All nurses would be educated on this form. Any nurse not educated would not be allowed to work the floor until the education was completed. Nurses would complete this assessment on resident admission and with resident change of respiratory condition.
• New legionella filters were received and placed on the main floor bathroom sink, therapy room sink, room [ROOM NUMBER] sink faucet, shower heads on the second, third and forth floors, at the nursing station sinks on the second, third and forth floors and on the dialysis center sinks by Maintenance Manager #322.
• Legionella tests for six residents who were transferred from the facility for signs and symptoms of respiratory distress were completed.
• A contracted plumbing company ([NAME] Plumbing) came to the facility to evaluate appropriate adapters to fit on the sink filters. They also evaluated sanitation. The water remained off to the room sinks at this time.
• The DON/designee completed resident assessments (legionella assessment data collection form) for all facility residents. The resident assessments would continue to be conducted weekly by the DON/designee and/or Infection Preventionist. Any concerns would be immediately reported to the Administrator and Medical Director for follow-up.
• The facility Water Management Committee, including the Administrator, DON, IP #302, Maintenance Manager #322, Housekeeping/Laundry Supervisor, RT Director and Dietary Manager met to further discuss the facility's Water management -Legionella plan.
• The facility QAPI committee met to review any updates to the water management plan and complete audits.
• The facility new water management protocols included: a.) Each faucet and shower head aerator would be cleaned with an approved scale and lime build-up cleaner semi-annually to ensure proper water flow quarterly. b.) The hot water boilers would be set at 140 or greater. Facility staff would record the temperature of each hot water device weekly and adjust immediately if less than 140. To ensure compliance to policy, staff would retest the following day to confirm appropriate temperature. c.) Hot water holding tanks would be set at a minimum of 140 to inhibit the growth of Legionella and other opportunistic pathogens. Facility staff would record the temperature weekly and adjust immediately if less than 140 to ensure compliance. d.) Regular cleaning and changing of filters would be done per manufacturers' recommendations. The facility would remove scale and clean using approved cleaning agents semi-annually and changing the filters every six months or per manufacturer recommendations. Maintenance Manager #322 would audit monthly to ensure compliance and audits will be reviewed in QAPI meetings. e.) Weekly flushing of water would be added to housekeepers assignments which would consist of flushing for three minutes each faucet and showers also flush all toilets at least once every week. The supervisor would review documentation weekly to ensure compliance. Audits would be reviewed, and the facility would determine where the failure occurs during QAPI meetings. f.) If the facility experiences one or more positive cases of legionellosis, the facility would conduct semi-annual testing to determine if the water management plan (WMP) was effective in controlling legionella and the Maintenance Manager #322 will follow up with the vendor to determine failure to conduct and correct this. g.) For any positive legionella in the water, the facility would contact PT enterprises, to conduct testing on water samples, provide alternate water sources for bathing and patient care, inspect all faucets for built-up scaling and cleaning with appropriate cleaner and replace all filters on incoming water sources. h.) Legionella filters would be changed per manufacturers' recommendations.
• The facility received ordered parts which were being installed with a plan to have all installation of parts/filters completed.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to renew its food service operation license in a timely manner, resulting in a period during which there was no valid license for the kitchen. This deficiency was identified through observation of the expired license posted in the kitchen, review of records showing the license expiration and late renewal application, and interviews with the Dietary Manager and Administrator. The Administrator confirmed that the renewal application was submitted late and the corporate office delayed issuing the payment for the renewal. As a result, all 35 residents who received food from the kitchen were affected during the lapse in licensure, except for five residents who had orders for nothing by mouth. The facility census at the time was 40 residents. The deficiency was substantiated by documentation showing the required application was not completed and submitted by the due date, and the check for the license fee was also issued late. There was a documented gap between the expiration of the previous license and the issuance of the updated license, during which the facility operated its food service without a valid license.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee included the minimum required members and met the participation requirements. Review of QAPI meeting sign-in sheets from July 2024 through February 2025 showed no evidence of attendance by the Medical Director, and the Infection Preventionist (IP) was not present at all required meetings, with gaps in attendance and certification. The sign-in sheets did not document the Medical Director's virtual attendance, and there was no written evidence of his participation in the meeting minutes. Additionally, the previous IP left in August 2024, and the new IP did not obtain the required certification until January 2025, leaving a period without a qualified IP present at meetings. Interviews with the DON confirmed that the Medical Director typically attended QAPI meetings by phone due to personal circumstances, but this was not documented. The Medical Director himself could not recall his last attendance and stated his participation was usually virtual, with updates provided by the facility. The facility's QAPI policy, last revised in October 2017, did not specify committee member requirements, and no other relevant policies were provided. These findings indicate the facility did not maintain the required composition and documentation for its QAPI committee, potentially affecting all residents.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the staff member responsible for overseeing the infection prevention and control program (IPCP) had completed the required specialized training in infection prevention and control. The designated Infection Preventionist (IP) began her training in August 2024, but her predecessor left after only eight hours of training, leaving her to learn the role independently. She did not complete the necessary training and obtain her certificate until January 2025. Review of her personnel file confirmed there was no evidence of completed specialized training prior to this date. Interviews with the Director of Nursing (DON) and other staff confirmed that, during the period between the previous IP's departure and the new IP's completion of training, there was no qualified staff member overseeing the IPCP. Additionally, the job description for the Infection Preventionist Director position did not require completion of specialized training before or after assuming the role. This lapse had the potential to affect all 40 residents in the facility.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide evidence that the physician conducted required in-person examinations for all new admissions, as mandated. Record reviews for four residents admitted from short-term general hospitals revealed that there were no progress notes written by the physician in the electronic health records for any of these residents. Instead, all documented examinations and follow-up visits were completed by a Certified Nurse Practitioner (CNP), with the physician either participating via telemedicine or not mentioned as participating at all. The CNP's notes consistently indicated that evaluations were completed via telehealth or telemedicine, and there was no documentation of the physician being physically present for any of the required visits. Interviews with facility staff, including the Director of Nursing (DON), an LPN, and the CNP, confirmed that the physician typically attended meetings and resident visits virtually due to personal circumstances, specifically his inability to leave his wife. The DON and LPN both stated that the CNP usually conducted resident visits, with the physician participating remotely via telemedicine. The LPN described a process where nurses would initiate a video call with the physician and move the device from room to room, while most communication with the physician was conducted by phone. The CNP verified that visits were conducted virtually if indicated in the progress notes and acknowledged that the physician's participation was not always documented. The CNP also stated that the progress note would specify if the physician or CNP conducted any portion of the visit in-person, but in these cases, there was no such documentation. The lack of in-person physician examinations and insufficient documentation of physician involvement led to the deficiency cited by surveyors.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide evidence that the physician did not delegate tasks to non-physician providers that were required to be completed personally by the physician. For four residents admitted from short-term general hospitals, medical record reviews showed that there were no progress notes written by the physician, who also served as the facility's Medical Director, documenting participation in the admission examinations. Instead, admission evaluations were completed by a Certified Nurse Practitioner (CNP) via telehealth or telemedicine, with no documentation of the physician's involvement in these assessments. Interviews with facility staff, including the Director of Nursing (DON), an LPN, and the CNP, confirmed that the physician often participated in meetings and resident visits via telephone or telemedicine due to personal circumstances. However, there was no documentation in the residents' records to verify the physician's participation in the admission process. The CNP also stated she was unaware of any law prohibiting her from completing initial visits via telemedicine, and verified that visits were conducted virtually if indicated in the progress notes.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide required spend-down notices to two residents whose funds were managed by the facility and whose account balances exceeded the Medicaid asset limit. For one resident with moderate cognitive impairment and multiple diagnoses including vascular dementia and major depressive disorder, quarterly account statements showed balances above the $2,000 Medicaid limit, but no spend-down notices were issued. Similarly, another resident with no cognitive impairment and a history of neurocognitive disorder and traumatic brain injury also had account balances above the allowable Medicaid limit, and did not receive any spend-down notices. Interviews with the Business Office Manager confirmed that the facility was aware of the Medicaid asset limit and that no spend-down notices were provided to any residents, including those whose balances exceeded the limit. The Director of Nursing confirmed that one resident was losing Medicaid coverage due to being over the asset limit, and would only regain coverage after spending down the excess funds. The deficiency was identified through record review and staff interviews, affecting two of five residents reviewed for resident funds.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete a new Pre-Admission Screening and Resident Review (PASRR) level two evaluation for a resident after a new diagnosis of Schizoaffective disorder was added. The resident was initially admitted with multiple medical conditions, including muscle weakness, hypothyroidism, protein-calorie malnutrition, encephalopathy, cellulitis, hypokalemia, hypertension, and cognitive communication deficit. The initial PASRR level one screening indicated no serious mental illness and no recent use of psychotropic medications. However, subsequent hospital records documented unspecified psychosis, adjustment disorder, refusal of medical treatment, and a determination of incompetence to make informed healthcare decisions. Following admission, the resident received several new orders for antipsychotic medications, and a new diagnosis of Schizoaffective disorder was formally added. Despite these significant changes in the resident's mental health status and treatment, the facility did not complete a new PASRR evaluation as required. This was confirmed during an interview with the Admissions Coordinator, who acknowledged that a significant change PASRR should have been completed for the resident.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide evidence that a baseline care plan was developed in a timely manner for a resident admitted with multiple complex medical conditions, including hypertension, iron deficiency anemia, bronchiectasis, atrial fibrillation, dementia, severe malnutrition, diabetes, pressure ulcers, enterocolitis due to clostridium difficile, open wound, and end stage renal disease. The resident's medical record review showed that the handwritten baseline care plan document lacked a date of completion, signature, or identification of the person who completed it. Additionally, there was no indication that the resident or their representative received a copy of the baseline care plan. Further review revealed that comprehensive care plans for several critical focus areas, such as nutrition and hydration risk, end-stage renal disease and hemodialysis, hypertension, fall risk, activities of daily living self-care deficit, incontinence, renal failure, clostridium difficile, pain, polypharmacy, discharge planning, and others, were not initiated within 48 hours of admission as required. The DON confirmed that baseline care plans were always completed on paper, not in the electronic health record, and verified the lack of documentation and communication regarding the baseline care plan for this resident.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement person-centered, comprehensive care plans that addressed the identified needs of two residents. For one resident with diagnoses including end stage renal disease, diabetes, heart failure, and bladder dysfunction, the care plan did not include interventions for elimination status, specifically omitting catheter care and bowel incontinence management, despite the resident having an indwelling catheter and frequent bowel incontinence. Interviews with facility staff confirmed that such interventions should have been present in the care plan and linked to aide documentation tasks, but were not. For another resident with a history of encephalopathy, weakness, dementia, and a previous fall resulting in a fractured ankle, the care plan lacked interventions for fall risk, even though fall risk assessments consistently indicated a moderate risk. The only fall-related care plan was marked as resolved after the previous fall, and no new interventions were documented despite ongoing risk. Staff interviews confirmed that care plan interventions for fall prevention should have been included, and facility policy required identification and documentation of fall risk factors and implementation of preventive interventions.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to re-evaluate and update the care plan with new interventions for a resident who experienced multiple falls over several months. Despite repeated incidents, the care plan was not revised to reflect new or different interventions after each fall, as required by facility policy and regulatory standards. The care plan contained duplicate interventions with different dates, and new interventions implemented after falls were not consistently added to the resident's care plan. The resident involved had a complex medical history, including neurocognitive disorder with Lewy bodies, major depressive disorder, dementia, and a history of traumatic brain injury. The resident was identified as being at high risk for falls, with multiple documented falls occurring both from bed and wheelchair, often while attempting self-transfers or sitting on the edge of the bed. After each fall, interventions such as education on call light use, neurological checks, and environmental adjustments were documented in progress notes and fall investigations, but these were not systematically incorporated into the formal care plan. Interviews with the Director of Nursing confirmed that the care plan was not updated after each fall and that there were duplicate interventions listed. The DON acknowledged ongoing challenges with the resident's memory and behavior due to Lewy Body Dementia but could not identify additional measures to prevent further falls. Facility policy required care plans to be revised when the desired outcome was not met or when the resident's condition changed, but this was not followed in the case of this resident.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that smoking materials were stored in a safe and secure location, as required by facility policy, affecting two residents identified as independent smokers. Both residents were permitted to smoke independently and were observed to keep their smoking materials, including cigarettes, lighters, and a vape cartridge, in their rooms rather than in the designated locked storage as outlined in the facility's smoking policy. Multiple staff interviews revealed uncertainty and inconsistency regarding the enforcement of the policy, with some staff unsure whether independent smokers were allowed to keep their smoking supplies in their rooms. For one resident, who had diagnoses including encephalopathy, alcohol dependence with persisting dementia, and tobacco use, observations revealed a strong odor of smoke in the resident's room, a vape cartridge found on the floor near an oxygen concentrator, and confirmation from the resident that she kept her smoking materials in her room or coat pocket. Staff interviews confirmed that smoking materials were supposed to be locked in the medication cart, but this was not being followed for this resident. The resident's care plan and signed smoking agreement both required that smoking materials be locked up, but these interventions were not implemented. Similarly, another resident with a history of alcohol and nicotine dependence and a cognitive communication deficit was also found to keep smoking materials in his room, contrary to facility policy. Staff interviews and observations confirmed that this resident, too, was not following the policy requiring smoking materials to be locked up. Both residents' care plans and signed agreements specified that smoking materials should be secured, and any infraction would result in loss of smoking privileges, but these measures were not enforced. The facility's own policy and procedure documents reiterated the requirement for locked storage of smoking materials, which was not adhered to in these cases.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the appropriate and timely administration and maintenance of an intravenous (IV) midline catheter for a resident with multiple complex medical conditions, including diabetes, acute kidney failure, necrotizing fasciitis, osteomyelitis, sepsis, and chronic ulcers. The resident was ordered to receive IV antibiotics and saline flushes through a midline catheter, but after the completion of the antibiotic course, there were no physician orders for continued flushing to maintain line patency or for regular IV dressing changes. Documentation showed that the last antibiotic dose and saline flush were administered several days prior, and there was no record of any IV dressing changes during the period reviewed. Observation revealed that the resident's IV dressing had not been changed since insertion, and the IV tubing and bag remained hanging on the pole days after the last use. The resident confirmed not receiving any IV medications or flushes in several days, and the dressing had never been changed. An LPN interviewed was unable to locate any orders for dressing changes and confirmed the dressing was outdated. Facility policy required midline catheters to be flushed at least every 24 hours and dressings to be changed within 24 hours of insertion and then every five to seven days, but these protocols were not followed.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that pharmacist recommendations regarding a resident's medication regimen were reviewed and addressed by the physician. Specifically, a pharmacist recommended increasing the dosage of Metformin for a resident with multiple complex diagnoses, including end stage renal disease, heart failure, hypertension, anxiety, major depressive disorder, necrotizing fasciitis, overactive bladder, neuromuscular dysfunction of the bladder, and type 2 diabetes mellitus. The recommendation was documented in the pharmacist consultation report, but there was no evidence in the medical record, medication administration records, or progress notes that the physician or other prescribing provider reviewed or acted upon this recommendation. The resident in question had intact cognition and was receiving several medications, including hypoglycemics, antidepressants, diuretics, opioids, and anticonvulsants. Despite the pharmacist's recommendation to adjust the Metformin dosage, the medication order remained unchanged for several months, and no documentation was found indicating that the recommendation was considered by the medical staff. Additionally, the facility was unable to provide a policy related to monthly medication regimen reviews when requested.

Penalty

Inspection fine: $179,23514 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a complete and accurate medical record for Resident #34. Resident #34, who had diagnoses including end stage renal disease, chronic obstructive pulmonary disease, pleural effusion, and type one diabetes mellitus, was admitted to the facility and later discharged to the hospital. Despite the resident not having returned from the hospital, a Legionella signs and symptoms assessment was documented for Resident #34, including vital signs recorded on a date when the resident was still hospitalized. The assessment was completed by an LPN, who could not recall the specifics of completing the assessment for this resident or the source of the information documented. Further review of the resident's census information, progress notes, and MDS assessments confirmed there was no evidence that Resident #34 had returned to the facility at the time the assessment was completed. Observations and interviews with facility staff, including a CNA and the DON, verified that the resident remained in the hospital and that the room was empty. The DON confirmed the assessment's date and content, and the LPN acknowledged completing multiple assessments but could not explain the documentation for this particular resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of an as-needed antianxiety medication for Resident #22. The resident, who had a complex medical history including encephalopathy, end stage renal disease, and anxiety disorders, received lorazepam multiple times without any documented attempts of non-pharmacological interventions. This was confirmed through a review of the medical records and an interview with the Director of Nursing, who verified that non-pharmacological interventions were not attempted prior to the administration of lorazepam on several occasions in March and April 2024. Additionally, the facility did not ensure that the as-needed lorazepam order for Resident #22 included a stop date, as required by regulations. The resident's physician's order for lorazepam one milligram IM every four hours as needed for anxiety and agitation, dated 03/15/24, lacked a stop date. This was also confirmed by the Director of Nursing during an interview. The facility's policy on psychotropic drugs was reviewed and found to be in place to promote the utilization of such drugs in accordance with accepted principles of geriatric medicine and long-term care practice, but it was not followed in this instance.