**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to acquire, receive, dispense, and administer an ordered anti-seizure medication for 1 of 1 residents reviewed. (Resident #39) The findings include: A record review of Resident #39 was conducted on 05/17/2023 at approximately 9:30 AM. Resident #39 was admitted on [DATE] with diagnoses of epilepsy, Alzheimer's disease, dementia, major depressive disorder, type 2 diabetes, atrial fibrillation, chronic kidney disease, anxiety disorder, and asthma. Resident #39 had an order for Carbamazepine 200 milligrams, one tablet by mouth to be given at bedtime. A review of the Medication Administration Record (MAR) for April 2023 revealed that Resident #39 did not receive this medication on 04/25/2023, 04/27/2023, and 04/30/2023. Progress notes entered by nursing staff on 04/25/2023, 04/27/2023, and 04/30/2023 revealed that the Carbamazepine tablets were not on hand. Review of Resident #39's care plan revealed she had a diagnosis of seizure disorder. The care plan interventions were to give the medications as ordered by the doctor. The Unavailable Medications policy (dated October 2022) states that the facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed, and emergency medications. The policy further reads, The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. The staff are to take immediate action when a medication is unavailable to include: 1. Determine the reason for unavailability, length of time to get the medication and what efforts have been attempted to obtain the medication. 2. Notify the physician of the inability to obtain the medication. An interview was conducted on 05/17/2023 at approximately 10:25 AM with the Director of Nursing (DON). The DON stated the facility medications are obtained from an outside pharmacy twice daily. The staff can obtain medications by fax, online, or by phone. The DON stated, We do have a local pharmacy, if we do not have the needed medications in our RX machine. The DON stated, The East Wing Unit Manager is responsible for making sure the medications are in the building. I was not aware that the resident did not receive her medications on the dates listed on the MAR. It is odd that she was able to receive them on two of those days (04/28/2023-04/29/2023) and then not again on the 30th. I will follow up with the pharmacy and the unit manager. The DON stated she would expect the facility medications to be ordered and escalated if the staff were not able to acquire them in time. The DON stated, I would expect a resident to receive her anti-seizure medication as ordered. Another interview was conducted with the DON at approximately 11:00 AM on 05/17/2023. The DON stated that approximately two months ago, the facility removed some medications from the RX List that were not used frequently. Carbamazepine was removed. The DON stated, I can get the pharmacy to add it for the future. The Carbamazepine was ordered by the staff, but it was not shipped on the 25th. Another nurse sent a handwritten communication to them. The Unit Manager was not notified. We normally see any missed medications in the 24-hour daily report. From now on, they will have to just notify me of any missing medications. An interview was conducted on 05/17/2023 at approximately 11:35 AM with the East Wing Unit Manager (UM). The UM stated she does risk management for the facility and supervises the certified nursing assistant (CNAs) and nurses. The UM stated, The facility has risk rounds, where events or issues that may have happened that night are looked at. Honestly, I had to have missed that medication (Carbamazepine). I was out for a few days. I don't even know if that was around during that timeframe or not. Normally, the staff would usually just tell me everything, most of the time. But they just didn't this time and I missed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and admission packet review, the facility failed to ensure each resident bedroom was equipped with means for privacy for 2 of 18 sampled occupied resident rooms. (Rooms 605 A and 608 A) The findings include: Observations of occupied room [ROOM NUMBER] A were conducted on 5/16/23 at 8:57 AM and 5/16/23 at 1:15 PM. room [ROOM NUMBER] A was not equipped with a privacy curtain or curtain track. (Photographic evidence obtained.) Further observation of room [ROOM NUMBER] A was conducted in the presence of the Administrator on 5/16/23 at 3:15 PM. The Administrator stated room [ROOM NUMBER] A was once a private room and confirmed bed 605 A was not equipped with a privacy curtain or curtain track. Observations of occupied room [ROOM NUMBER] A were conducted on 5/15/23 at 2:00 PM and 5/17/23 at 9:58 AM. The privacy curtain near the doorway in room [ROOM NUMBER] A was about 2 feet too short in width to provide full visual privacy to the resident in room [ROOM NUMBER] A. (Photographic evidence obtained.) Further observation of room [ROOM NUMBER] A was conducted on 5/17/23 at 10:16 AM in the presence of the Environmental Director. He stated he was responsible for ensuring the privacy curtains provide residents with full visual privacy. The Environmental Director observed the curtain in room [ROOM NUMBER] A and confirmed the curtain was about 2 feet too short in width to provide full visual privacy. He stated the facility had no set process to check the curtains except during terminal cleans when a resident moves out or if the curtain is soiled. The resident admission packet states,The resident has the right to personal privacy and to confidentiality of your personal and clinical records. Personal privacy includes privacy in accommodations, medical treatment, payment for services, written and telephone communications, personal care, visits, and meetings of family and resident groups.

Based on observations, staff interviews and policy review, the facility failed to ensure proper storage of medications for 1 of 17 residents (#67) sampled. The findings include: On 12/13/21 at 12:58 PM, an observation was made of Resident #67. A medication cup containing a white pill and a disk inhaler was observed on the overbed table. The resident stated the white pill was a Tylenol used to treat mild pain, and the disk inhaler was Advairdiskus 250mcg/50mcg used to treat Asthma. There was no staff present in the room at the time of the observation. (photographic evidence obtained) A review of the facility policy LTC Facility Pharmacy Services and Procedures Manual revised 10/31/16 revealed next to item 3.3, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 12/14/21 at 1:21 PM, an interview was conducted with Nurse A, a Registered Nurse (RN) who was assigned to Resident #67 on 12/13/21 during the day shift (7 AM to 7 PM). Nurse A stated, The resident was supposed to be taking the medication as I was exiting the room and did not make me aware that she did not take all of them. Nurse A continued, Normally I do stay with the resident until they complete their medications, but the resident was doing something else, so I was going to come back to her. Our policy is for us to stay with the resident while taking their medication, and I am not sure what pulled me away so that was my mistake. On 12/14/21 at 1:37 PM, an interview was conducted with the Director of Nursing who stated her expectation is for the nurse to stay with the resident while administering the medication and to take the medication with them when leaving the room.