Health inspection·May 24, 2024

F 0550 Right Hip; Other Heart Failure; Atrioventricular Block. Level of Harm - Minimal harm or potential for actual harm On 05/21/24 at 11:55 AM, R92 was observed as being alert and oriented to person, place, and time during this interview. R92 stated call light answer times is her only complaint. R92 stated on average it takes 15 minutes she'd say to have the light answered, but stated recently it was 2 hours she had to wait. R92 stated she mostly utilizes her call light for restroom needs and finds 15 minutes to be longer than she'd prefer, but 2 hours to be way too long. R92 stated staff will say they've been busy helping other residents when they finally respond to her light. R92 stated she is able to confirm the times expressed by evidence of watching the clock, which was visible. Residents Affected - Some 3. R103's admission Record documented R103 as being an [AGE] year-old male with an original admission date to the facility as 9/13/23. Diagnoses on this form included but were not limited to: Generalized Anxiety Disorder; Restlessness and Agitation; Unspecified Dementia, Unspecified Severity, with Agitation. On 05/21/24 at 10:50 AM, V5 (Family Member) stated call lights aren't always answered timely. V5 stated she has witnessed it firsthand when she has been here visiting R103. V5 stated on average she would say it takes staff 20 minutes to answer a call light routinely. R103's Current Plan of Care with a date initiated of 9/19/23 documented a focus area of impaired cognitive function/dementia or impaired thought process. 4. R56's admission Record documented an original admission date to the facility as 7/1/22. R56 is documented as being a [AGE] year old female with diagnoses including but not limited to: Secondary Parkinsonism, Unspecified; End Stage Renal Disease; Nontraumatic Subarachnoid Hemorrhage, Unspecified, etc. R56's Minimum Data Set (MDS) with an Assessment Reference Date of 2/27/24 documented a Brief Interview for Mental Status Score of 13, indicating she's cognitively intact. On 05/21/24 at 09:53 AM, R56 was observed sitting in her wheelchair in her room, with a mechanical lift sling underneath her. R56 was observed being alert and oriented to person, place, and time. R56 stated her only concern with the facility is the amount of time it takes staff to answer call lights, specifically to use or get off the toilet. R56 stated that the average time it takes for call lights to be answered is 30 minutes she would say, but up to 2 hours. R56 stated she can confirm these times by the use of the clocks in her room, clocks visualized during this interview. R56 stated this seems to be the worst first thing in the morning, and then after lunch and around 2 PM. R56 stated she has experienced incontinence episodes waiting for staff to take her to the restroom, as well as neck pain, waiting so long for staff to get her off the commode. On 5/22/24 at 12:31 PM, V3 (Certified Nurse Assistant, CNA) stated that she works from 6 AM - 2 PM at the facility, usually on 200 hall. V3 stated that she feels like the facility has enough staff, as there are generally 4 CNA's and a nurse staffed on 200 hall. V3 stated that 200 hallway is just heavy care with several residents requiring the assistance of two staff at a time for tasks. V3 stated she answers the call lights in the order she sees them illuminate, and as quickly as possible. V3 stated at times residents are having to wait for staff assistance, it is because staff are busy working with other residents. On 5/22/24 at 12:38 PM, V4 (CNA) stated that he normally works from 6 AM - 2 PM on the 200 hall. V4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Rehab & Healthcare Center 800 West Temple Street Effingham, IL 62401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated that he feels like the facility has enough staff. V4 stated that there are just times when multiple heavy care residents need assistance, which takes up time and the amount of staff available to assist others. V4 stated when residents are having to wait for assistance, it is due to staff being with other resident's, not that they are just standing around. On 5/23/24 at 2:00 PM, V6 (CNA) stated although she cannot give specific resident names, she acknowledges she has had resident's complain to her regarding call light answer times and recognizes staff response times could be improved. V6 stated that on the 200 hall for the 2 PM- 10 PM shift, there are usually 3 CNA's scheduled and one nurse. V6 stated that 200 hall has heavy care resident's that require a lot of staff time. On 5/22/24 at 12:54 PM, V1 (Administrator) stated that the facility does not have a staffing policy, and the facility follows regulatory guidelines for staffing needs. V1 stated that there have been concerns presented to her on and off, stemming from resident council meetings regarding long call light wait times. V1 stated that the facility will go through periods where the times will be reported as being better, then worse again. V1 stated the facility has explored different options to try and improve call light wait times, including dispersing heavy care residents on different halls in the facility, looking at the staffing needs, staff productivity, etc. On 5/23/24 at 1:50 PM, V1 stated that her expectation is that call light be acknowledged by staff within 5 minutes. Review of the Resident Council meeting minutes as provided by the facility made the following concern notations: 12/18/23 - Nursing: Call light times are better. Still takes a little time @ (at) shift change & meal times but is better. 1/29/24 - Nursing: Don't feel like nurses or CNA's listen to concerns. Long call light wait times 2/28/24 - Nursing: Long wait times between shift changes. Esp. (especially) between 1st & 2nd shift. 3/27/24 - Nursing: Long call light wait times .Nursing not prioritizing resident needs over other duties. 4/24/24 - Nursing: CNA Nurses always huddled at desk. CNA on phone too much. A Grievance Form dated 1/29/24 with the Resident Name listed as Resident Council documented, .Call light wait time is too long. Difficulty getting staff to get them up in time for activities, especially in the afternoon. Resident has fallen asleep waiting for call light to be answered and when he wakes up, it has been turned off . Review of the 200 hall (Facility Name) Daily Census dated 5/22/24, provided by V2 (Regional Nurse) documented 8 (R3, R7, R8, R12, R56, R63, R68, R84) of 35 residents residing on the hall utilize a mechanical lift, requiring the assistance of 2 staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Rehab & Healthcare Center 800 West Temple Street Effingham, IL 62401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify resident representatives in writing of hospital transfers for 2 of 2 (R36, R71) residents reviewed for hospitalization in a sample of 51. The Findings Include: 1. R36's admission profile documents and admission date of 9/12/23. This same document lists V8 (Family Member) as the Power of Attorney (POA). R36's Quarterly Minimum Data Set (MDS) dated [DATE] documents a 7 for a Brief interview of Mental Status (BIMS) indicating a cognitive impairment. R36's progress notes document that 4/22/24 R36 was transported to the local emergency room after experiencing a change in condition. 2. R71's admission profile sheet documents an original admission date of 8/7/23. This same document lists V9 (Family Member/Power of Attorney) as the emergency contact. R71's 4/21/24 Quarterly MDS documents a BIMS score of 9 indicating a cognitive impairment. R71's progress notes documents that on 11/23/23 R71 was transported to the local emergency room due to experiencing a change of condition. On 5/23/25 at 2:00 PM, V1 (Administrator) stated that they call the resident family/Power of Attorney (POA) via phone when a resident is being transferred, but only send transfer paperwork with resident to the receiving hospital. V1 confirmed that they do not provide written documentation to the POA or family member regarding hospital transports including reasons of transport and bed hold policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Rehab & Healthcare Center 800 West Temple Street Effingham, IL 62401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify resident representatives in writing of the bed hold policy during resident transfer for 2 of 2 (R71 and R36) residents reviewed for hospitalization in a sample of 51. The Findings Include: 1. R36's admission profile documents and admission date of 9/12/23. This same document lists V8 (Family Member) as the Power of Attorney (POA). R36's Quarterly Minimum Data Set (MDS) dated [DATE] documents a 7 for a Brief interview of Mental Status (BIMS) indicating a cognitive impairment. R36's progress notes document that 4/22/24 R36 was transported to the local emergency room after experiencing an change in condition. 2. R71's admission profile sheet documents an original admission date of 8/7/23. This same document lists V9 (Family Member/Power of Attorney) as the emergency contact. R71's 4/21/24 Quarterly MDS documents a BIMS score of 9 indicating a cognitive impairment. R71's progress notes documents that on 11/23/23 R71 was transported to the local emergency room due to experiencing a change of condition. On 5/23/25 at 2:00 PM, V1 (Administrator) stated that they call the resident family/Power of Attorney (POS) via phone when a resident is being transferred, but only send transfer paperwork with resident to the receiving hospital. V1 confirmed that they do not provide written documentation to the POA or family member regarding hospital transports including reasons of transport and bed hold policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Rehab & Healthcare Center 800 West Temple Street Effingham, IL 62401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to revise a care plan to include medications ordered for a Urinary Tract Infection (UTI) for 1 (R115) of 24 residents reviewed for care plans in the sample of 51. Findings Include: R115's admission Record documented R115 as a [AGE] year old with an admission date to the facility of 03/29/2024. Diagnosis listed include other nontraumatic intracerebral hemorrhage, Type 2 Diabetes Mellitus, Parkinsonism, Aphasia following nontraumatic intracerebral hemorrhage, obstructive and reflux uropathy, gastrostomy, muscle weakness, cerebral infarction, hyperlipidemia, essential hypertension, obstructive sleep apnea. R115's MDS (Minimum Data Set) dated 4/5/24 documented 0 under section C0100 titled Should brief Interview for Mental Status be conducted?, indicating the resident is rarely / never understood. R115's current Order Summary Report documented Bactrim 800-160 mg (milligrams) two times a day for bacterial infection with an order date of 05/20/2024. Review of document labeled local hospital laboratory result, with a date of 05/15/2024, documented a urine culture result of >100,000 Proteus Mirabillis with a sensitivity to Bactrim. R115's Current Care Plan documents a Focus area of: R115 has a catheter: obstructive uropathy. Date initiated 4/26/24. An intervention included: Monitor/record/report to MD (Medical Doctor) for s/sx (signs/symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date initiated 4/26/24. R115's Care Plan does not document that R115 is on antibiotics for a UTI. On 05/24/2024 at 9:20 A.M. V2 (Regional Nurse) stated it is her expectation that any medication should be care planned. On 05/24/2024 at 9:25 A.M. V2 (Regional Nurse) stated the facility does not have a policy on care plans. They follow state guidelines. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Rehab & Healthcare Center 800 West Temple Street Effingham, IL 62401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure timely assistance was provided for toileting needs for 1 (R56) of 6 reviewed for Activities of Daily Living in the sample of 51. This failure resulted in R56 expressing undue feelings of frustration, embarrassment, and neck pain. Residents Affected - Few Findings Include: R56's admission Record documented an original admission date to the facility as 7/1/22. R56 is documented as being a [AGE] year old female with diagnoses including but not limited to: Secondary Parkinsonism, Unspecified; End Stage Renal Disease; Nontraumatic Subarachnoid Hemorrhage, Unspecified, etc. R56's Minimum Data Set (MDS) with an Assessment Reference Date of 2/27/24 documented a Brief Interview for Mental Status Score of 13, indicating she's cognitively intact. The same MDS documented in Section GG0130, Dependent care for toileting hygiene. Section GG0170 also documented a dependent status for toileting transfer. Section H0300 documented R56 as being frequently incontinent. R56's Plan of Care documented a focus area of ADL (Activities of Daily Living) Self Care Performance Deficit with a date initiated as 7/2/23. Interventions listed for this focus area document, The resident requires 2 staff participation to use toilet. On 05/21/24 at 09:53 AM, R56 was observed sitting in her wheelchair in her room, with a mechanical lift sling underneath her. R56 was observed being alert and oriented to person, place, and time. R56 stated her only concern with the facility is the amount of time it takes staff to answer call lights, specifically to use or get off the toilet. R56 stated that the average time it takes for call lights to be answered is 30 minutes she would say, but up to 2 hours. R56 stated she can confirm these times by the use of the clocks in her room, where were visualized during this interview. R56 stated this seems to be the worst first thing in the morning, and then after lunch and around 2 PM. R56 stated she has experienced incontinence episodes waiting for staff to take her to the restroom, as well as neck pain, waiting so long for staff to get her off the commode. R56 stated she finds it frustrating and embarrassing when she experiences incontinence and must be changed out of wet clothes and cleaned up. On 5/23/24 at 1:55 PM, R56 was alert and oriented to person, place and time. R56 again confirmed that she utilizes a commode for toileting needs. R56 stated that when left on the commode for prolonged periods of time, waiting for staff to come back and tend to her after being placed on the commode, she will experience a pain level in her neck she rates as a 7 on a 10 point scale, with 10 being the worst. R56 stated that she does not receive pain medication at these times for her neck, as the pain is relieved once repositioned off the commode. R56 confirmed that she does experience incontinence, but stated she knows when she is experiencing incontinence for the most part, and the incontinence stems from waiting for staff assistance. On 5/23/24 at 2:00 PM, V6 (Certified Nurse Assistant) stated that she worked the 2 PM - 10 PM shift, frequently on the 200 hall. V6 stated that R56 does utilize a commode for toileting needs and can appropriately utilize her call light. V6 stated that R56 is frequently incontinent by the time staff answer her call light. V6 stated that R56 has previously had a stroke so she isn't sure if R56 doesn't push her call light early enough for staff to get to her before she's incontinent but confirms (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Rehab & Healthcare Center 800 West Temple Street Effingham, IL 62401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Actual harm Residents Affected - Few there are times R56 is continent on the commode, even after experiencing incontinence. V6 stated although she cannot give specific resident names, she acknowledges she has had residents complain to her regarding call light answer times and recognizes staff response times could be improved. V6 stated that on the 200 hall for the 2 PM- 10 PM shift, there are usually 3 CNA's scheduled and one nurse. V6 stated that 200 hall has heavy care resident's that require a lot of staff time. On 5/22/24 at 12:31 PM, V3 (Certified Nurse Assistant, CNA) stated that she works from 6 AM - 2 PM at the facility, usually on 200 hall. V3 stated that she feels like the facility has enough staff, as there are generally 4 CNA's and a nurse staffed on 200 hall. V3 stated that 200 hallway is just heavy care with several residents requiring the assistance of two staff at a time for tasks. V3 stated she answers the call lights in the order she sees them illuminate, and as quickly as possible. V3 stated at times residents are having to wait for staff assistance, it is because staff are busy working with other residents. On 5/22/24 at 12:38 PM, V4 (CNA) stated that he normally works from 6 AM - 2 PM on the 200 hall. V4 stated that he feels like the facility has enough staff. V4 stated that there are just times when multiple heavy care residents needs assistance, which takes up time and the amount of staff available to assist others. V4 stated when residents are having to wait for assistance, it is due to staff being with other resident's, not that they are just standing around. On 5/22/24 at 12:54 PM, V1 (Administrator) stated that the facility does not have a staffing policy, and the facility follows regulatory guidelines for staffing needs. V1 stated that there have been concerns presented to her on and off, stemming from resident council meetings regarding long call light wait times. V1 stated that the facility will go through periods where the times will be reported as being better, then worse again. V1 stated the facility has explored different options to try and improve call light wait times, including dispersing heavy care residents on different halls in the facility, looking at the staffing needs, staff productivity, etc. On 5/23/24 at 1:50 PM, V1 stated that her expectation is that call light be acknowledged by staff within 5 minutes. On 05/23/24 at 02:51 PM, V7 (Medical Director) agreed that his expectations would be for staff to tend to call light answer times as soon as possible. V7 acknowledges that a commode could potentially be uncomfortable and if a resident was expressing discomfort and unsatisfactory wait times, those concerns would need addressed and evaluated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145256 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Rehab & Healthcare Center 800 West Temple Street Effingham, IL 62401 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure as needed psychotropic medications were ordered for a specific duration for 2 (R52, R103) of 7 reviewed for unnecessary medications in the sample of 51. Findings Include: 1. R103's admission Record documented R103 as being an [AGE] year-old male with an original admission date to the facility as 9/13/23. Diagnoses on this form included but were not limited to: Generalized Anxiety Disorder; Restlessness and Agitation; Unspecified Dementia, Unspecified Severity, with Agitation. R103's Order Details include an order with a start date of 2/28/24 for, LORazepam Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth every 12 hours as needed for behaviors and increased anxiety. No duration for the use of this medication was noted. 2. R52's admission Record documented R52 as being a [AGE] year-old female with an original admission date to the facility as 12/27/23. Diagnoses on this form included but were not limited to: Generalized Anxiety Disorder. R52's current Physician Orders include an order with a start date 2/5/24 for, LORazepam Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 0.5 mg by mouth every 12 hours as needed for Anxiety. No duration for the use of this medication was noted. On 05/23/24 at 9:10 AM, V2 (Regional Nurse) stated that she had spoken with pharmacy and was under the impression no end date for an as needed anti-anxiety medication was needed if clinical rationale for the continued use was documented. Review of the facility policy titled, Psychotropic Medication Use with a reviewed date of 09/2022 documented, .8. The timeframe for PRN (as needed) psychotropic medications, which are not antipsychotic medications, will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145256 If continuation sheet Page 9 of 9