Based on interview and record review, the facility failed to assess and evaluate the resident's clinical condition and risk factors for developing urinary tract infection (UTI, an infection in the bladder and urinary tract) for one of 5 sampled residents (Resident 1), when the resident experienced weakness and difficulties with urination. This failure had the potential to delay the provision of care and treatment for Resident 1 and placed the resident at risk for unnecessary pain and emotional distress. A review of the admission Record indicated the facility admitted Resident 1 in early 2025 with multiple diagnoses which included history of prostate cancer (cancer of the prostate gland, located below the bladder) and acute kidney failure (AKF, a condition when kidneys fail to filter waste and extra water suddenly potentially causing health problems; one of the causes of AKF is blockage of urinary tract).A review of Resident 1's Minimum Data Set (MDS, - a federally mandated resident assessment tool), dated 6/19/25, indicated Resident 1 was cognitively intact. The MDS assessment indicated Resident 1 had ability to urinate but was frequently incontinent.During a concurrent observation and interview on 7/22/25, commencing at 2:30 p.m., Resident 1 was observed sitting in wheelchair in his room. Resident 1 was alert and oriented and answered all questions appropriately. Resident 1 stated that last week he started having lots of pain in his lower abdomen, the bladder area. Resident 1 described that the pain was sharp and when asked to rate the pain on a scale of zero (0) to 10, where 10 is the worst pain he had ever experienced, the resident stated the pain was 10 out of 10. Resident 1 added, I could not urinate. Had urge but only a few drops would come out. Resident 1 stated he had a history of frequent UTI's, and he knew the symptoms of UTI. Resident 1 stated he and his wife told his nurse that he was in pain and was unable to urinate, and felt like I had another UTI, and asked to be sent to emergency department (ED).During a continued interview on 7/22/25, at 2:30 p.m., Resident 1 explained that nurses used a bladder scanner (a portable electronic ultrasound device used to measure the amount of urine in a bladder) in the past to check if he was retaining the urine due to blockage, but that particular evening his nurse did not scan his bladder, did not check his blood pressure, and did not offer pain medications.During a continued interview on 7/22/25, at 2:30 p.m., Resident 1 stated that his blood pressure was very high when he arrived at ED. Resident 1 explained that the physician tested his urine at ED and he was diagnosed with UTI. Resident 1 added that he was sent back to facility with a prescription for antibiotic (medications to treat infection).A review of Resident 1's clinical records contained a nursing progress note dated 7/17/25, at 9:57 p.m., which indicated, Was called .to assess the resident. Resident is alert and oriented .Family member (wife) is at bedside stated that his husband is acting different (facing [sic] out and weak), and that his husband can't pee. The nurse documented that the resident was transferred to ED.A review of Resident 1's clinical records contained no documented evidence the nurse assessed the resident's pain, his vital signs, including blood pressure, heart rate, respiratory rate, and temperature. There was no documented evidence the nurse assessed resident's abdomen for distension or used a bladder scanner to check if he was retaining urine. During a concurrent interview and record review on 7/22/25, at 1:17 pm., with the Director of Nursing (DON), the DON acknowledged that the Resident 1's electronic clinical records did not contain resident's assessment. The DON stated that nursing notified her that evening regarding Resident 1's condition and added, The resident was fine.This was his wife's request to send the resident to ED. The DON stated the facility documented resident's assessment on a paper document that was sent with the resident to ED.During an interview and record review with DON on 7/22/25, at 1:43 p.m., the DON provided a document titled, SBAR [situation, background, assessment, recommendation, communication tool for MD [Medical Doctor], transfer to ER/Acute/Other facility, dated 7/17/25. The instruction on SBAR document directed the nurse Situation: State the problem .when it happened or started, and how severe. Background: Pertinent background information related to the situation.include the following: .most recent vital signs.Other clinical information.Assessment: What is the nurse's assessment of the situation? The nurse documented, Pt [patient's] wife reports pt [patient] acting different.patient is weak & spacing out.History of UTI. The SBAR document did not contain the information when the resident started experiencing issues with weakness, spacing out, and inability to urinate, how severe the problem was, did not include vital signs, and had no resident's assessment as instructed.During a review of the document with DON on 7/22/25, at 1:43 pm., the DON acknowledged that the SBAR document was not completed properly. The DON validated there was no resident's assessment, no vital signs, and other information related to Resident 1's issues with spacing out and inability to urinate. The DON agreed that the resident had multiple medical conditions which could possibly increase his risk for UTI or urine blockage. The DON added that the expectation for the nurse was to assess the resident's mental status, vital signs, pain, and a bladder scan to assess if the resident retained urine, but it was not done. The DON validated that Resident 1 was diagnosed with UTI when he was sent to ED and the physician prescribed the antibiotics to treat his infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect two residents (Resident 1 and Resident 2) from abuse, when the staff witnessed Resident 1 hitting Resident 2 in the head and Resident 2 grabbing Resident 1's forearm. In addition, the facility failed to assess and document Resident 1's skin injury and the treatment that was provided. This failure resulted in Resident 2 being hit on the head and Resident 1 receiving skin tears to right forearm and had the potential to result in emotional distress for Resident 1 and Resident 2. Findings: A review of the admission record indicated the facility admitted Resident 1 in 2021 with multiple diagnoses, which included dementia (a progressive state of decline in mental abilities) and depression. A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 5/8/25, indicated the resident scored 10 out of 15 for Brief Interview for Mental Status (BIMS, an assessment tool used to screen and identify memory, orientation, and judgement status of the resident), which indicated moderate impaired cognition. A review of Resident 1's interdisciplinary care plan dated 5/20/25 indicated, RESIDENT TO RESIDENT ALTERCATION, Resident displayed inappropriate treatment of another resident; Resident received inappropriate treatment from another resident. The nursing interventions directed staff to ensure safe environment and perform body check for injuries. A review of the admission record for Resident 2 indicated the facility admitted the resident in 2015 with multiple diagnoses which included dementia and anxiety. A review of Resident 2's MDS dated [DATE] indicated the resident BIMS of 10, which indicated moderate impaired cognitive status. A review of Resident 2's interdisciplinary care plan, dated 5/20/25 indicated, RESIDENT TO RESIDENT ALTERCATION, Resident displayed inappropriate treatment of another resident; Resident received inappropriate treatment from another resident. A review of the nursing alert notes for Resident 1, dated 5/20/25, at 5:02 p.m., indicated, Residents were gathered in dining room with activity staff present. This resident . walked down .and tapped another resident [Resident 2] . in the head with an open hand. The note further indicated that Resident 2 grabbed Resident 1's arm and dug in his nails leaving several deep scratches. The note indicated that first aid to Resident 1 was administered. A review of Resident 1's clinical record, including skin and wound assessments failed to reveal the facility staff assessed and documented the resident's skin injury obtained during the altercation with Resident 2. There was no documented evidence that nursing staff documented the location, measurements, description of the injuries, and treatment that was provided. During an interview on 6/3/25, at 9:30 a.m., the Director of Nursing (DON) validated that there was a witnessed altercation between Resident 1 and Resident 2 on 5/20/25. The DON stated the facility had difficulty to determine who was the victim and added, [Resident 1] was the one that initially tapped [Resident 2] on his head, but he ended up being injured. During an observation and interview on 6/3/25, at 10:05 a.m., Resident 1 was observed laying in his bed. Resident 1 responded appropriately to questions asked. Resident 1 was observed having a few scattered bruises and three scabs on his right forearm. Resident 1 explained, This guy [Resident 2's name] grabbed my arm and my skin got ripped. You see, my skin is so thin .was bleeding . lots of blood. My arm was sore. Resident 1 added, He [Resident 2] took offence on something I had said. I don't remember what I said. During an observation and interview with Resident 2 on 6/3/25, at 10:15 a.m., Resident 2 was observed in his bed. When Resident 2 was asked about the altercation with Resident 1, the resident stated, My memory is gone completely . I can't recall if I hurt him and I don't remember if he hurt me. If I did, I can't recall. During an interview with facility staff (FS) on 6/3/25, at 11:04 a.m., the FS stated that the altercation between Resident 1 and Resident 2 happened on 5/20/25, around 5 p.m. The FS stated Resident 1 was standing in front of Resident 2 and both were swinging their arms like attempting to punch each other and then [Resident 2] suddenly grabbed [Resident 1's arm. The FS stated the incident happened very quickly after which Resident 1's forearm started bleeding and the resident's nurse was notified of the skin injuries. During an interview with Licensed Nurse (LN 1) on 6/3/25, at 11:30 a.m., LN 1 stated she was notified by FS that [Resident 1] hit [Resident 2] in the head after which [Resident 2] grabbed [Resident 1's] forearm and squeezed hard. LN 1 stated Resident 1 had three skin tears and they were bleeding. LN 1 stated the photo of skin tears was taken on 5/20/25 and the description of the injuries to Resident 1's forearm should be found under skin and wound assessment in the resident's clinical record. Upon reviewing the record, LN 1 was not able to locate the assessment, description of skin tears or picture of Resident 1's injuries. During a follow up interview and record review with DON on 6/3/25, at 12 p.m., the DON provided a document titled, [Name of the facility] skilled nursing new skin condition and explained that this checklist was used every time the nurses observed resident having a new skin issue. The DON stated that per LN 1's documentation, Resident 1's skin and wound assessment and a progress note about the wound were completed and signed on 5/20/25 and validated that the resident's clinical record did not reflect any wound/skin assessment documentation dated 5/20/25. The DON stated the expectation was that nurses followed the facility protocol and documented skin tears assessment in Resident 1's clinical record. A review of the facility's 'Abuse Policy,' with the revision date of 8/24, indicated, It is the policy of the Skilled Facility to promote an environment free from any type of abuse for all of its residents .After identification of any type of abuse, a full head to toe assessment must be done on the resident/s and documented in the medical record . Any bruising .skin tear .will be documented .Any visible injuries should be photographed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain mobility and prevent further decrease in range of motion for two of 16 sampled residents (Resident 22 and Resident 34), when: 1. Resident 22's physician's order and care plan's interventions for the management of his left arm weakness and left hand contracture (shortening and hardening of muscles and ligaments leading to deformity, rigidity of joints, and loss of motion) were not followed, and 2. Resident 34 did not receive restorative nursing assistant (RNA, exercises to improve or maintain resident's functional abilities) services consistently per physical therapy (PT) recommendations and her care plan's interventions. These failures placed Resident 22 and Resident 34 at risk for further complications and decline in their physical functioning and mobility. Findings: 1. A review of the admission record indicated the facility admitted Resident 22 in 2019 with multiple diagnoses including brain bleed (stroke) resulting in resident's left-sided paralysis, muscle weakness, and left hand contracture. A review of a physician order dated 12/21/21 indicated Resident 22 was to wear a sling for comfort to support his weakened left arm during the day. A review of Resident 22's Minimum Data Set (MDS, a standardized assessment tool used to plan resident's care) dated 9/21/23 indicated the resident had no cognitive impairment. The section of the MDS titled Functional Limitations in Range of Motion, indicated that Resident 22 had impairment of upper extremity, including shoulder, elbow, wrist, and hand) on one side. A review of 'Resident [22's] Care Guide' (care plan) dated 9/28/23 indicated, I wear a .sling to support my left upper extremity .When out of bed, I wear a soft L [left] hand roll with my .sling .to prevent contracture .Please, remember to help me don my .sling when I am out of bed. During a concurrent observation and interview on 10/2/23, at 12:25 p.m., Resident 22 was sitting in his wheelchair in his room. Resident 22's left hand fingers were curled into his palm and he did not have a hand roll. Resident 22 did not have a sling on and used his right hand to support his left arm to it from slipping off the wheelchair's armrest. When the resident was asked if he had any assistive devices to support his left arm, Resident 22 stated he used to have a sling but did not know where it was or what happened to it. Resident 22 added, I've lost it a while ago, I think three or four months ago . I think laundry lost it. I asked . my CNAs to look for it, and they couldn't find it. Resident 22 stated that it was more comfortable to have a sling on to support his left arm, but nobody offered to look for it or to order a new sling. During an observation of Resident 22's room, a sign 'Sling and Splint Schedule' was noted taped to the door to resident's closet. The sign indicated, Wear L [left] arm sling during day for comfort as tolerated. Next to that sign was posted another sign with instructions for 'Sling Tips' directing nursing staff to don the sling whenever the resident wanted to wear his sling. During a concurrent observation on 10/3/23, at 11:30 a.m., Resident 22 was sitting in the dining room in his wheelchair. There was no sling to support Resident 22's left arm and from time to time the resident was noted to support his left arm with his right arm. During an interview on 10/3/23, at 12:10 p.m., Licensed Nurse (LN 1) stated she was familiar with Resident 22's care. LN 1 stated that Resident 22's left arm was flaccid (limp and weak) and added that the resident should have a sling when he is in his wheelchair to support the arm. LN 1 stated she did not notice if Resident 22 had it on earlier when she administered his medications. LN 1 stated Resident 22's left hand was contracted and he was to hold onto a soft roll to prevent his contracture from worsening. During an interview on 10/3/23, at 12:17 p.m., Certified Nursing Assistant (CNA 1) stated that Resident 22 had to wear a sling and a little spongy ball in his left hand to prevent further contracture. CNA 1 stated a sling and hand roll were stored in the resident's room in a little basket. During an observation on 10/3/23, at 12:30 p.m., Resident 22 was observed in the wheelchair in his room. Resident 22 did not have the sling to support his left arm and there was no soft roll in his left hand. Resident 22 stated, I need to support my left arm because it sometimes slips of the wheelchair. Resident 22 added that he had to hold onto a little foamy ball to prevent his fingers from curling more. During a concurrent interview on 10/3/23, at 12:47 p.m., the facility's Physical Therapist (PT) and Occupational Therapist (OT) stated that Resident 22 received therapy services at present. The OT stated that the resident had to wear the sling for his left arm. The OT explained that the resident had a foamy soft hand roll to manage his left-hand contracture and needed frequent reminders to grab and hold onto it to prevent his hand contracture from worsening. The OT stated that she had not seen Resident 22 wearing his sling lately and added, Sometimes things get misplaced. During an observation on 10/4/23, at 11:20 a.m., Resident 22 was observed sitting in wheelchair in without his sling and soft roll. During an interview on 10/4/23, at 11:28 a.m., LN 2 stated she was familiar with Resident 22 and his care. LN 2 stated the resident had a physician order to wear the sling to support his paralyzed left arm while he was in his wheelchair. LN 2 stated Resident 22 was not wearing the sling lately and was not able to explain why the physician's order was not followed and the resident had not been wearing the sling. During an interview on 10/4/23, at 2:02 p.m., the Director of Nursing (DON) stated that Resident 22 should have had his left arm sling on every day to maintain his comfort and good body position. The DON stated the expectation for nursing staff was to follow a physician order and follow the care plan's interventions reminding the resident to keep a hand roll to prevent further contractures to his left hand. The DON added that if the sling was lost, the facility should have ordered a new sling as soon as possible and if the resident refused to wear the sling, his physician should have been notified. 2. A review of the admission record indicated the facility admitted Resident 34 a year ago with multiple diagnoses including multiple sclerosis (a chronic disease of the central nervous system affecting person's vision, balance, mobility, and emotions). Resident 34's history indicated that the resident had multiple falls with injuries in the past related to the resident's weakness and poor balance. A review of Resident 34's MDS assessment dated [DATE] indicated the resident had no cognitive impairment. Resident 34's functional status assessment indicated that she had weakness on both lower extremities and required staff's assistance to ambulate. A review of Resident 34's 'Care Guide' (care plan) revised 7/13/23 indicated that the resident had progressive lower extremities weakness and impaired balance. The care plan indicated that to maintain her strength, balance, and safety, Resident 34 received RNA services two times a week using the exercise bike and ambulating with her walker. The care plan's goal indicated that Resident 34 will maintain her functional independence and mobility. A review of the physical therapist Discharge summary dated [DATE] indicated that Resident 34 met maximum potential and was discharged from physical therapy services on 8/18/23. The PT discharge summary indicated that the resident was referred to restorative nursing services to improve her mobility and decrease risk for falls. The discharge summary contained instructions for RNA staff to follow while ambulating and exercising Resident 34. A review of Resident 34's weekly nursing assessments dated 8/27/23, 9/4/23, 9/11/23, and 10/1/23 indicated that the resident was on RNA program. During an observation and interview on 10/2/23, at 9:19 a.m., Resident 34 was observed lying in her bed. Resident 34 stated she was dizzy and lightheaded when she attempted to stand up and walk and required staff's assistance. Resident 34 stated she had had multiple falls in the past. When Resident 34 was asked if she was on RNA program, the resident replied, Sometimes they exercise me on that bike. During a continued interview, Resident 34 stated the staff assisting her to the bathroom were the only exercises she received lately. During an interview on 10/4/23, at 8:47 a.m., RNA 1 stated that Resident 34 had been on the RNA program for a long time. RNA 1 explained that Resident 34's RNA program included ambulating and exercising on the bike twice a week. RNA 1 stated that the residents, including Resident 34 have not been receiving RNA services for weeks because she had been working the floor as certified nursing assistant (CNA). RNA 1 explained that she was the only RNA in the entire facility trained to provide RNA services and added, When I'm working as CNA, residents don't get their exercises. RNA 1 stated she had not offered RNA services to Resident 34 in three weeks. A review of the RNA Program report provided by the RNA 1 indicated that Resident 34 was offered RNA exercises four times in the month of August 2023, instead of eight times. A review of the RNA program report indicated that Resident 34 was offered RNA exercises one time in the month of September 2023 instead of eight times. There was no documented evidence that Resident 34 was offered RNA services from 10/1 through 10/4/23. During an interview with DON on 10/4/23, at 2:15 p.m., the DON stated that the facility had issues with providing their residents with RNA services and acknowledged that residents' care plans were not followed consistently. The DON stated that the facility had one trained RNA and she was pulled from the RNA program to take over CNAs assignments frequently. The DON stated RNA program was important for Resident 34 to help her stay safe and to prevent worsening of the resident's mobility and added, It's our goal that residents don't lose their ability to walk. A review of the facility's policy and procedure titled, Restorative Care Program, with the revision date of 4/21, indicated the purpose of the policy was To maintain [residents] quality of life. The policy further indicated that the facility offered a Restorative Nursing program to any resident .who is identified as needing the services .to improve and/or maintain joint ROM [Range of Motion], normal body alignment and overall functional strength, mobility .to increase resident self-esteem .to minimize the effects of disability.

Based on interview and record review, the facility failed to respond in a timely manner to a medication irregularity for one of 16 sampled residents (Resident 8), when the facility did not follow up on a Pharmacy Consultant (PC) recommendation to discontinue nitrofurantoin (antibiotic, a medication to treat infections) for 56 days. This failure placed Resident 8 at an increased risk for developing adverse drug consequences (unwanted, uncomfortable, or dangerous effects) from the prolonged use of an antibiotic medication. Findings: A review of the admission record indicated the facility admitted Resident 8 earlier this year with multiple diagnoses which included chronic pain and a history of urinary tract infections (UTI-an infection of the urinary track which includes the kidney, bladder, or urethra). A review of the physician order dated 2/4/23 indicated, Nitrofurantoin . 50 MG [milligram, unit of measurement] .Give 1 capsule by mouth one time a day for UTI prophylactic (a medication used to prevent disease). A review of the clinical record for Resident 8 contained a pharmacy consultant (PC) report titled, Consultation Report, dated 8/8/23. The PC report indicated a recommendation to discontinue nitrofurantoin and initiate another medication while monitoring for signs and symptoms of UTI. The PC documented, Rationale for Recommendation: The potential for developing pulmonary fibrosis [a serious lung disease that occurs when lung tissues becomes damaged and scarred resulting in difficulty to breathe], hepatotoxicity [liver damage], C difficile infection [inflammation of the colon resulting in diarrhea and pain], and peripheral neuropathy [a condition peripheral nerves become damaged resulting in pain, numbness, and weakness in the hands and feet] increases with duration of use. The section of the report with the information of the physician's response to the pharmacist's recommendation, signature, and the date was blank. A review of Resident 8's clinical records indicated there was no documented evidence the facility acted upon the recommendation to discontinue nitrofurantoin and order another antibiotic recommended by PC. A review of Resident 8's medication administration records (MARs) for August 2023 and September 2023 indicated that the resident continued to receive nitrofurantoin 50 mg every morning after the PC wrote the recommendation to discontinue the medication. A review of Resident 8's MARs from October 1 through October 4, 2023 indicated Resident 8 continued receiving nitrofurantoin 50 mg every morning. During a concurrent interview and record review on 10/3/23, at 11:40 a.m., the facility's Infection Preventionist (IP) confirmed that the facility did not act upon a pharmacist recommendation dated 8/8/23 to discontinue nitrofurantoin. The IP added, We had no DON for three (3) months, and it was missed. A review of the facility's policy titled, Medication Regimen Review, with a revision date of 8/17/23, indicated, The Consultant Pharmacist will conduct MRRs [medication regiment reviews] and will make recommendations based on the information available in the residents' health record .Facility should encourage Physician/Prescriber .and the Director of Nursing to act upon the recommendations contained in the MRR .Facility should encourage Physician/Prescriber to either accept and act upon the recommendations .or reject .recommendations .and provide an explanation as to why the recommendation was rejected. During an interview on 10/4/23, at 2:05 p.m., the DON stated that the facility should have acted upon the pharmacy consultant's recommendation to discontinue nitrofurantoin within 72 hours after receiving the report and added, We missed it.

Based on observation, interview and record review, the facility failed to ensure medications were kept safe and secure for 2 of 12 sampled residents (Resident 16 and Resident 21) and 3 non-sampled residents (Resident 3, Resident 32, and Resident 33) when residents medications were on top of the overbed table mixed with food condiments and personal items. These failures had increased residents risks for unsafe medication storage and food hazards. Findings: 1. Resident 16 was admitted in 2015. A review of the physician's order, dated 4/6/15 indicated, [Brand name, antifungal powder that absorbs moisture while helping to prevent skin irritation] topically to folds of bilateral breasts daily as needed for redness. A review of the physician's order dated 4/6/15, indicated Resident 16 has the capacity to make health care decisions. Documentation regarding Self-Medication Administration Assessment was requested from Licensed Nurse 2 (LN 2), but no document was provided. During an observation and interview on 6/5/19 at 11:54 a.m., on 6/6/19 at 2 p.m. and at 4:22 p.m., there was a hard plastic bottle labeled [Brand Name, treatment powder] on top of the over-bed table mixed with food condiments and personal items. Resident 16 was asked, What do you use this powder for? Resident 16 looked at the plastic bottle and stated, I don't know what is that bottle for. During an observation and interview on 6/7/19 at 10:32 a.m., LN 2 acknowledged the observation and stated, That plastic bottle was a powder treatment medication . it should not be in the over-bed table .it should be kept in the treatment cart. 2. Resident 21 was admitted in 2016 with diagnoses which included allergic rhinitis (allergic response to specific allergens). A review of the physician's order dated 12/9/17 indicated, [Brand Name for nasal spray] 0.05 mg [milligram, unit of measurement]/1 Actuation Spray, ****May keep at bedside**** 1 spray nasal Every Day each nostril for Allergic Rhinitis. A review of the physician's order dated 7/18/18 indicated, [Brand name, eye drops for eye irritation] 1.4% solution [Polyvinyl alcohol] 1 drop into each eye Ophthalmic Q [every] 6 hours as Needed *MAY KEEP OTC [over the counter] AT BEDSIDE* for eye irritation. A review of the physician's order dated 3/21/16 indicated Resident 21 has the capacity to make health care decisions. Documentation regarding Self-Medication Administration Assessment was requested from LN 2 but no document was provided. During an observation and interview on 6/6/19 at 9:57 a.m., the plastic bottles of the eye drops and the nasal spray were on top of the over-bed table, mixed with food condiments, water pitcher, plastic urinal, and personal items. When asked, Do you keep these [eye drops and nasal spray] in your over-bed table? Resident 21 stated, Yes, I keep it here [pointing the over-bed table]. During an observation and interview on 6/6/19 at 12:09 p.m., LN 1 acknowledged the observations and stated, Yes, medications were on the over-bed table and should not be mixed with food condiments, it should be kept safe at the bedside. 3. Resident 3 was admitted in late 2018 with diagnoses which included chronic obstructive pulmonary disease (COPD), and hypoxemia (low level of oxygen in the blood). A review of the physician's order dated 11/15/18 indicated, Resident 3 had the capacity to make health care decisions. A review of the Self Medication Administration Assessment questions dated 11/16/18 indicated, How much do you take each dose was left blank. The Interdisciplinary Team (IDT, person-centered team of health care providers) Recommendations was also left blank. A review of the physician's order dated 11/15/18 indicated, [Brand name, to prevent and treat wheezing and shortness of breath] 0.09 mg/1 Actuation Suspension: 2 puffs inhalation as needed every 4 hours for shortness of breath (SOB). Ok per MD (Medical Doctor) to keep at bedside and self administer. A review of Resident 3's care plan dated 5/30/19 indicated, My doctor is concerned that I may overuse it [puff inhaler], so please ask me about use each shift and document how often I have used it. During an observation on 6/5/19 at 11:54 a.m., on 6/6/19 at 2 p.m., and on 6/6/19 at 4:22 p.m., 2 canisters of air puffs medications were on top of the over-bed table and mixed with food condiments and personal items. During an observation and interview on 6/5/19 at 10 a.m. and on 6/7/19 at 11 a.m., when asked about the air puff at the over-bed table, Resident 3 stated, Yes, I keep it here in my table .I used it whenever I wanted .they took away the other canister because the nurse said it was empty .nobody even checked if I used it or not . During an observation and interview on 6/6/19 at 11 a.m., LN 3 confirmed, [Resident 3] had order to keep medication at bedside .[Resident 3] used it if she wants it or not. 4. Resident 32 was admitted in 2017 with diagnoses which included irritable bowel syndrome (IBS). A review of the physicians order dated 5/22/17 indicated, Digestive Enzymes 500 mg tablet (enzymes) 1 tablet Oral Three times Daily for Gastric Distress **Self -Administer by Resident -- Kept at Bedside--Family Will Provide Medications**. A review of the physician's order dated 5/22/17 indicated Resident 32 had the capacity to make health care decisions. Documentation regarding Self-Medication Administration Assessment was requested from LN 2 but no document was provided. During an observation on 6/5/19 at 10:30 a.m., on top of Resident 32's over-bed table were personal items, 3 bottles of different supplements, and food condiments. Resident 32 was asked about those bottled supplements, but was unable to answer. During an observation and interview on 6/6/19 at 11:13 a.m., LN 1 stated, Yes [Resident 32] kept her 3 bottles of supplement in her over-bed table .it is her room .I assumed she is taking it. 5. Resident 33 was admitted in 2018 with diagnoses which included dementia (gradual decrease in the ability to think and remember). A review of the physicians order dated 6/7/19 indicated, [Brand name, eye drops] 1.4% solution 1 drop to each eye ophthalmic as needed every four hours for dry eyes. May keep at bedside and self administer PRN [as needed]. A review of the physician's order dated 7/9/18 indicated, Resident 33 does not have the capacity to make health care decisions. A review of the Self-Medication Administration Assessment questions dated 1/10/19 indicated, How much do you take each dose? was left blank. The Interdisciplinary Team (IDT) Recommendations was also left blank. During an observation and interview on 6/5/19 at 10:24 a.m., Resident 33's overbed table was observed with 1 plastic bottle of eye drops, 1 plastic bottle of rubbing ointment, food condiments and personal items. Resident 33 stated, The eye drop, I used for my eyes, the rubbing ointment, I used for my nose. During an observation and interview on 6/7/19 at 11: 07 a.m., LN 2 acknowledged the observation and stated, Eye drops and the rubbing ointment should not be left on the over-bed table. During an interview on 6/6/19 at 2:36 p.m., the Consultant Pharmacist (CP) stated, My expectation was that the doctor should put it in the order may self medicate . the nurse to monitor if they are really self administering it . I agree the nurse should first ask the resident if they take it or not, document and then adjust the order as necessary . A review of the facility's policy and procedure titled, Patient Care Services and Support Services, dated 12/17, indicated, Patient care delivery occurs through a process designed to ensure the delivery of safe, effective, timely care, and treatment. A review of the facility's policy and procedure titled, Patient Care Services and Support Services, dated 12/17, indicated, The medication management function is a vital component of the patient care delivery system .monitor and assess .preparation .dispensing .administering of drugs .and their effects on patients . A review of the facility's policy and procedure, titled, Self Administration of Medications, dated 1/97, indicated, To ensure the resident is assessed for their ability to safely administer .if a physician order exists .storage at bedside is allowed for non-prescription . prescription medications that are ordered for self administration will be kept in a locked cabinet within the residents' room .residents are re-evaluated in the case of suspected non-compliance . A review of the facility's policy and procedure titled, Patient Care Services and Support Services, dated 12/17, indicated, Medications are stored in a secured manner, regardless of their location in the facility.