**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Self-Administration of Medications by Patients/Residents, the facility failed to assess one of 37 sampled residents (R) (R35) for the ability to safely self-administer medications prior to leaving medications at the bedside. This deficient practice had the potential to place R35 at risk of unsafe medication use. Findings include: Review of the facility's policy titled Self-Administration of Medications by Patients/Residents, reviewed 1/6/2025, revealed the Policy Statement stated, Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. Medication self-administration also applies to family members who wish to administer medication. Review of R35's Face Sheet revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypercapnia, and hypertension. Review of R35's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Pattern) documented a Brief Interview for Mental Status (BIMS) score of 6 (indicating severe cognitive impairment). Review of R35's care plan, dated 2/12/2025, revealed no care area or interventions for medication self-administration. Review of R35's Physician Orders revealed an order dated 8/13/2024 for ipratropium-albuterol solution (a medication used to treat lung diseases) for nebulization (the administration of a solution in the form of a fine mist directly into the lungs), 0.5 milligrams (mg)-3 mg/ 3 milliliters (ml) three times a day. Further review of the orders revealed no order for self-administration of medication. Review of the Medication Administration Record (MAR) from 2/4/2025 to 3/4/2025 revealed documentation that staff administered the ipratropium-albuterol solution as ordered. Review of the clinical record revealed R35 did not have a self-administration of medication assessment to indicate the resident was capable of medication self-administration. Observation on 3/4/2025 at 10:06 am of R35's nightstand revealed a cup sitting on the nightstand containing nine albuterol solution ampules. In an interview, R35 stated that she self-administered albuterol nebulizer treatments three times daily in the morning, after lunch, and after dinner and would take additional doses as needed when experiencing excessive coughing. Observation on 3/4/2025 at 12:06 pm revealed the albuterol solution ampules remained at the bedside. During a concurrent observation and interview on 3/4/2025 at 3:01 pm, Registered Nurse (RN) CC revealed that R35 was not permitted to self-administer breathing treatments or keep albuterol medication in her room. RN CC confirmed the cup containing albuterol ampules on R35's bedside table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and record reviews, the facility failed to ensure one of 37 sampled residents (R) (R72) call light was within reach. This deficient practice had the potential to place R72 at risk of unmet needs and increased risk of injury. Findings include: Review of R72's medical record revealed diagnoses including, but not limited to, cognitive communication deficit and impaired mobility. Review of R72's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 13 (indicating little to no cognitive impairment), and Section GG (Functional Abilities and Goals) documented R72 required partial to moderate assistance with mobility. Review of R72's care plan, dated 2/10/2025, revealed the resident was at risk for falls related to impaired mobility, received psychotropic medication, and had weakness. Interventions included placing the call light within reach. Observations on 3/4/2025 at 9:49 am and 12:03 pm and 3/5/2025 at 12:57 pm revealed R72 seated in a wheelchair in her room behind a privacy curtain with no call light within reach. In an interview on 3/5/2025 at 1:35 pm, R72 revealed that she was unable to reach her call light on multiple occasions. She stated that staff would sometimes leave it on the bed or in other places out of her reach, leaving her unable to call for help when needed. In an interview on 3/5/2025 at 1:50 pm, Certified Nursing Assistant (CNA) DD confirmed that the resident's call light was not within her reach and should be within reach at all times. She further stated that R72 would have no way to call for help with the light being out of her reach.

Based on observation, record reviews, staff interviews, and review of the facility's policies titled Expired Medication and Medication Storage in the Healthcare Centers, the facility failed to ensure expired medications were not stored in one of two medication storage rooms. This deficient practice had the potential to place the residents at risk of receiving medications with altered effectiveness. The facility's census was 72. Findings include: Review of the facility's policy titled Expired Medication, reviewed 6/18/2024, revealed the Policy Statement included . Expired medication must be removed from the active medication storage area and disposed of according to Assisted Living Community (ALC) policy. Review of the facility's policy titled Medication Storage in the Healthcare Centers, revised 11/1/2024, revealed the Procedure section included, . 3. Nurses are required to check all medications for deterioration and expiration before administration Observation on 3/5/2025 at 11:00 am of the medication room located at the Back Nurses' Station revealed two vials of naloxone HCL (hydrochloride) injection (a medication used to rapidly reverse an opioid overdose) 0.4 milligram (mg)/ milliliters (ml) with an expiration date of March 1, 2024, on each vial. In a concurrent interview and observation of the medication storage room on 3/5/2025 at 11:05 am, Unit Manager (UM) AA confirmed that the two vials of naloxone injection in the medication room were expired. She stated the expired medications should not be in the medication room and should have been removed before they expired. UM AA stated that if a resident received the expired medication, the medication could be less effective and might not work. In an interview on 3/5/2025 at 12:05 pm, Registered Nurse (RN) BB stated that expired medications should not be in the medication room because the use of expired medications could have adverse effects if administered to a resident. RN BB further stated that expired medications could be less potent and less effective. In an interview on 3/5/2025 at 12:22 pm, the Director of Health Services (DHS) stated her expectation was that expired medications should not be in the medication room. She stated that medications should be removed from the medication room before they expire by the nurse or UM. She further stated that naloxone was administered to counteract a narcotic overdose and that if the medication was expired, it could have a decreased desired effect.