**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure 1 (#87) of 5 (#9, #10, #30, #87, #317) residents reviewed for unnecessary medications were informed of the risks, benefits, and side effects of an antipsychotic medication prior to the start of the medication. Findings: Review of Resident #87's medical record revealed in part an admit date of 10/01/2023 with diagnoses including, but not limited to, dementia with psychotic disturbance and major depressive disorder. Review of Resident #87's Quarterly MDS (Minimum Data Set) dated 09/18/2024 revealed a BIMS (Brief Interview for Mental Status) of 11 indicating moderately impaired cognition. Further review of Resident #87's Quarterly MDS dated [DATE] revealed Resident #87 was taking an antipsychotic medication on a routine basis. Review of Resident #87's physician's orders revealed in part an order dated 09/03/2024 for Aripiprazole 2mg (milligram) by mouth every day. Review of Resident #87's electronic medication administration record for the month of September 2024 revealed Resident #87 received Aripiprazole as ordered. Review of Resident #87's medical record failed to reveal documentation Resident #87 or Resident #87's representative were informed of the risks, benefits, side effects and possible alternative treatment of an antipsychotic medication prior to the start of the medication. During an interview on 10/08/2024 at 11:13 a.m. S3 DON reported the facility did not have any documentation to confirm Resident #87 or Resident #87's representative had been informed of risk, benefits, side effects and possible alternative treatments of an antipyschotic medication.

Based on observation, record review, and interview, the facility failed to ensure that a resident was free from physical restraints imposed for purposes of discipline or convenience for 1 (#74) of 1 (#74) residents investigated for restraints. The facility failed to ensure: 1) Resident #74 had a written consent for a self-releasing seatbelt, pommel cushion, scoop mattress and side rails and was able to intentionally remove those items in the same manner as they were applied by the staff, 2) a physician's order was in place for the use of restraints. Findings: Review of the facility's Restraint/Device Policy last revised 10/2022 revealed in part: Restraints and Safety Devices: It is the philosophy of this facility that a resident has the right to be free from any physical or chemical restraints not required to treat the residents medical symptoms. Restraints may not be used for the convenience of the nursing staff or as punishment to the resident. Physical Restraint Definition: Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot easily remove, restricts freedom of movement or normal access to one's body. Any manual method or physical or mechanical device, material or equipment should be classified as a restraint only when it meets the criteria of the physical restraint definition. This is not determined by a type of device or method, but can only be determined on an individual basis by evaluating the effect it has on the resident. Do Not focus on the type, intent, or the reason behind the use to determine if it should be classified as a restraint, focus on the effect. The Restraint Device Worksheet helps to make the determination of whether the device is a restraint or not. If it is determined not to be a restraint, it is a device. If the device being used could be considered a restraint, the Device/Physical Restraint Consent shall be completed. Residents with new restraints must be reviewed weekly at the High Risk Management meeting until stable and reviewed monthly thereafter. Re-evaluate resident at least quarterly for possible restraint reduction. The facility must attempt to use appropriate alternatives prior to installing a side rail. If used, the facility must assess the resident of risk of entrapment, review the risks and benefits with the resident or resident representative, obtain informed consent prior to installation, ensure bed dimensions are appropriate for the resident's size and weight, and follow manufacturer's directions for installing and maintaining side rails. Restrained residents must be observed at least every 30 minutes. Restraints must be released at least every 2 hours, and the resident exercised, toileted, or repositioned. Review of Resident #74's medical record revealed an admit date of 10/01/2023 with diagnoses that include in part, spastic quadriplegic cerebral palsy, moderate intellectual disabilities, aphasia, major depressive disorder, bipolar disorder, mood affective disorder, and anxiety. Review of Resident #74's physician's orders failed to reveal an order for the use of device/restraints: seatbelt, scoop mattress, side rails and/or pommel cushion. Review of Resident #74's medical record failed to reveal a consent for use of Restraint/Device with risk and benefits discussed with Resident #74 or Resident #74's legal representative. Review of Resident #74's comprehensive care plan revealed in part the following risks/problems and interventions: current safety devices and special equipment initiated 08/29/2024: Anti roll back device, low bed with scoop mattress, seat belt with chest straps, side rails x 2, and wheelchair. Multiple observations during this survey 10/06/2024 through 10/09/2024 revealed Resident #74 sitting in her wheelchair with harness seatbelt and pommel cushion in use. Further observations revealed scoop mattress in place to Resident #74's bed with bed rails in use. During an interview on 10/09/2024 at 9:12 a.m. S2 Corporate Nurse reported when the Restraint/Positioning Device Worksheet was originally done the staff were answering the questions wrong and limiting the choices between restraints or devices. The facility did not consider the seatbelt, pommel cushion or side rails to be a restraint, but considered them a device and a device did not require a physician's order. S2 Corporate Nurse further reported the seatbelt was easy to remove, and was for Resident #74's safety and used as a device. S2 Corporate Nurse acknowledged Resident #74 could not remove the seatbelt herself.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately assess the residents discharge status for 1 (#116) of 1 (#116) resident reviewed for resident assessments out of a total sample of 31 residents. Findings: Review of Resident #116's medical record revealed an admit date of 07/03/2024 and discharge date of 07/15/2024 with diagnoses that included in part, aftercare following joint replacement surgery, and presence of right artificial knee joint. Review of Resident #116's nurses' notes revealed in part, on 07/15/2024 at 2:12 p.m. Resident #116 was discharged home today. Left per family vehicle with family. Review of Resident #116's discharge data collection form dated 07/16/2024 revealed in part, resident is being discharged to Home/Community. Type of discharge: unplanned. Additional Information: Resident discharged per self from facility, sister picked up, left with wheelchair that he brought with him on admit. He stated he just wanted to be home. Left with sister in private vehicle. Review of Resident #116's Discharge Minimum Data Set (MDS) dated [DATE] revealed in part, Section A: Identification Information: Discharge-return not anticipated. Planned . discharged to Short-term General hospital (acute hospital). During an interview on 10/07/2024 at 3:55 p.m. S6 MDS Coordinator acknowledged the discharge MDS was incorrect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews the facility failed to ensure residents who were unable to complete their ADL (Activities of Daily Living) received the necessary services to maintain proper grooming for 2 (#20 and #104) of 3 (#20, #36, #104) residents reviewed for ADLs. The facility failed to ensure Resident #20 and #104 received nail care. Findings: Nail Care Policy: Purpose - To promote cleanliness, safety and a neat appearance and to observe skin condition on fingers and toes. Procedure - 1. Perform hand hygiene. 4. Soak the resident's hand and feet in a basin of warm water for 10-15 minutes before trimming or trim following a bath. 7. Remove any debris from under the nails with the orangewood stick. Resident #20 Review of Resident #20's medical record revealed the following medical diagnoses including, but not limited to, type 2 diabetes mellitus, muscle wasting and atrophy, and fibromyalgia. Review of Resident #20's Quarterly MDS (Minimum Data Sets) dated 09/18/2024 revealed a BIMS (Brief Interview of Mental Status) of 13 indicating intact cognition. Review of Resident #20's care plan dated 12/26/2023 revealed the following, but not limited to, needs assist x 1-2 staff with all ADLs. During an observation on 10/08/2024 at 8:27 a.m. Resident #20 had brown debris under the nail beds. During an interview on 10/08/2024 at 8:29 a.m. Resident #20 reported she just got back from her morning shower. When asked if the staff cleaned under her fingernails, she reported no. During an interview on 10/08/2024 at 4:07 p.m. S7 LPN (Licensed Practical Nurse) confirmed Resident #20's fingernails were dirty with brown debris under the nail beds and needed to be cleaned. Resident #104 Review of Resident #104's MDS dated [DATE] revealed a BIMS score of 3 indicating severely impaired cognition. Review of Resident #104's care plan revealed the following including, but not limited to, needs assistance with ADLs, assist with ADLs as needed. An observation on 10/06/2024 at 2:04 p.m. revealed Resident #104's fingernails were long and yellow with brown debris under the nail beds. An observation on 10/08/2024 at 8:12 a.m. revealed Resident #104's fingernails were long and yellow with brown debris under the nail beds. During an interview on 10/08/2024 at 4:05 p.m. S7 LPN confirmed Resident #104's fingernails were dirty with brown debris under the nail beds and needed to be trimmed and cleaned.

Deficiency Text Not Available

Based on observations and interview the facility failed to ensure the most recent survey results were posted in a place readily accessible to the residents, family or visitors to review. Findings: Review of Resident #22's Quarterly MDS (Minimum Data Sets) dated 10/02/2024 had a BIMS (Brief Interview of Mental Status) of 15 indicating intact cognition. An observation on 10/06/2024 at 10:00 a.m. failed to reveal the most recent survey results were posted in a place that was readily accessible for review. During an interview on 10/08/2024 at 12:30 p.m. Resident Council President, Resident #22 reported she did not see the survey results. Resident #22 further reported she did not know where the survey results were posted and was not aware she could read the past survey results. During an interview on 10/08/2024 at 2:15 p.m. S2 Corporate Nurse confirmed the survey results were not posted in a conspicuous place for residents, visitors and family to find.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews, the facility failed to ensure correct use and maintenance of bed rails by ensuring residents were accurately assessed for the risk of entrapment from bed rails and an informed consent was obtained from resident or resident representative prior to installation for 15 (#10, #18, #20, #24, #30, #36, #51, #53, #57, #66, #75, #96, #101, #104, #106) out of 17 (#10, #18, #20, #24, #30, #36, #51, #53, #57, #66, #75, #96, #101, #104, #106, #167, #367) residents reviewed for bed rails. Findings: Resident #10 Review of Resident #10's medical record revealed a re-admitted date of 03/21/2024 with diagnoses including the following, but not limited to, cerebral ischemia, long term use of insulin, presence of right artificial shoulder joint, long term use of aspirin, type 2 diabetes mellitus, and hemiplegia. Review of Resident #10's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. Review of Resident #10's Quarterly MDS (Minimum Data Sets) dated 07/24/2024 revealed a BIMS (Brief Interview of Mental Status) of 15 indicating intact cognition. An observation on 10/06/2024 at 4:00 p.m. revealed Resident #10 in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/07/2024 at 2:15 p.m. revealed Resident #10 in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/08/2024 at 7:55 a.m. revealed Resident #10 in bed eating breakfast with the bed rails x 2 in the raised position at the head of the bed. Resident #18 Review of Resident #18's medical record revealed an admit date of 10/01/2023 with the following diagnoses including, but not limited to, adult failure to thrive, muscle weakness, lack of coordination, unspecified dementia, and major depressive disorder. Review of Resident #18's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. Review of Resident #18's Quarterly MDS dated [DATE] revealed a BIMS of 11 indicating mildly intact cognition. An observation on 10/07/2024 at 8:00 a.m. revealed Resident #18 was in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/08/2024 at 8:01 a.m. revealed Resident #18 awake and alert in bed with bed rails x 2 in the raised position at the head of the bed. Resident #20 Review of Resident #20's medical record revealed an admit date of 10/01/2023 with the following diagnoses including, but not limited to, atherosclerotic heart disease, muscle wasting and atrophy, fibromyalgia, type 2 diabetes mellitus, Review of Resident #20's Quarterly MDS dated [DATE] revealed a BIMS of 13 indicating intact cognition. Review of Resident #20's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/08/2024 at 8:30 a.m. revealed Resident #20's was in bed with bed rails x 2 in the raised position at the head of the bed. Resident #24 Review of Resident #24's medical record revealed in part an admit date of 10/01/2023 with diagnoses including, but not limited to, end stage renal disease and dependence on renal dialysis. Review of Resident #24's Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of Resident #24's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 8:45 a.m. revealed Resident #24 was sitting in bed with bed rails x 2 in the raised position at head of bed. During an interview on 10/06/2024 at 8:45 a.m. Resident #24 reported he does not use bed rails. An observation on 10/08/2024 at 7:55 a.m. revealed Resident #24 was in bed with bed rails x 2 in the raised position at the head of the bed. Resident #30 Review of Resident #30's medical record revealed the following diagnoses including, but not limited to, malignant neoplasm of liver, not specified as primary or secondary, unspecified convulsions, chronic obstructive pulmonary disease, Parkinsonism, peripheral vascular disease and primary osteoarthritis. Review of Resident #30's Quarterly MDS assessment dated [DATE] revealed a BIMS score was not given. Review of Resident #30's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/07/2024 at 08:30 a.m. revealed Resident #30 was in bed. Resident #30's bed had bilateral bed rails installed that did not fit the bed properly. The bed rails were in the raised positioned with gaps between the side of the bed's mattress and the bed rails. The bed rails were bent inward. During an interview on 10/09/2024 at 08:30 a.m. Resident #30 reported she used her bed rails to try to turn and position herself in the bed. Resident #36 Review of Resident #36's medical record revealed the following diagnoses including, but not limited to, hemiplegia and hemiparesis following a non-traumatic intracerebral hemorrhage affecting his left dominant side, type 2 diabetes and muscle weakness. Review of Resident #36's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. Review of Resident #36's most recent MDS dated [DATE] revealed a BIMS score was not given, but documented Resident #36 was severely cognitively impaired. An observation on 10/07/2024 at 8:30 a.m. revealed one quarter bed rail and one assist bed rail attached to Resident #36's bed. Resident #36 was non-verbal and unable to be interviewed. Resident #51 Review of Resident #51's medical record revealed an admit date of 07/15/2024 with the following diagnosis including, but not limited to, acquired absence of right leg below knee. Review of Resident #51's 5 day MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of Resident #51's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 9:05 a.m. revealed Resident #51 sitting in a wheelchair at the bedside. Further observation revealed a bed rail to each side of bed in raised position at the head of the bed. During an interview on 10/06/2024 at 9:05 a.m. Resident #51 reported using the bed rails sometimes for bed mobility. An observation on 10/07/2024 at 2:00 p.m. revealed Resident #51 was sitting in a wheelchair at the bedside talking with family. Further observation revealed a bed rail to each side of the bed in the raised position at the head of the bed. Resident #53 Review of Resident #53's medical record revealed an admit date of 08/14/2024 with the following diagnoses including, but not limited to, Pick's disease and mixed receptive expressive language disorder. Review of Resident #53's 5 day admit MDS dated [DATE] revealed a staff assessment of cognitive skills with a BIMS score of 3 indicating severely impaired cognition. Review of Resident #53's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/24 at 8:10 a.m. revealed Resident #53 was in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/07/2024 at 2:30 p.m. revealed Resident #53 was in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/08/2024 at 8:15 a.m. revealed Resident #53 sitting up in a wheelchair at the bedside. Further observation revealed bed rails x 2 in the raised position at the head of the bed. Resident #57 Review of Resident #57's medical record revealed the following diagnoses including, but not limited to, other intervertebral disc degeneration, lumbar region, other lack of coordination, and cognitive communication deficit. Review of Resident #57's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. Review of Resident #57's most recent MDS dated [DATE] revealed a BIMS score of 14 which indicating intact cognition. During an observations on 10/09/2024 at 08:30 a.m. revealed bilateral bed rails attached to Resident #57's bed. During an interview on 10/09/2024 at 9:35 a.m. Resident #57 reported she can only move her upper body and she uses the bed rails to help turn and reposition herself in bed. Resident #66 Review of Resident #66's medical record revealed the following diagnoses including, but not limited to, chronic obstructive pulmonary disease with acute exacerbation, Crohn's disease, muscle wasting and atrophy. Review of Resident #66's MDS dated [DATE] revealed a BIMS score 13 indicating intact cognition. Review of Resident #66's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. During an observation on 10/07/2024 at 08:30 a.m. Resident #66 had bilateral bed rails attached to her bed. During an interview on 10/09/2024 at 9:00 a.m. Resident #66 reported she uses the bed rails to help position herself in the bed. Resident #75 Review of Resident #75's medical record revealed an admit date of 10/01/2023 with the following diagnoses including, but not limited to, cerebral palsy, muscle weakness, moderate intellectual disabilities, spastic quadriplegic cerebral palsy, and cognitive communication disorder. Review of Resident #75's MDS dated [DATE] revealed a BIMS was not done due to the cognitive skills for daily decision making were severely impaired. Review of Resident #75's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 2:22 p.m. revealed Resident #75 in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/07/2024 at 8:00 a.m. revealed Resident #75 in bed with bed rails x 2 in the raised position at the head of the bed. Resident #96 Review of Resident #96's medical record revealed the following diagnoses including, but not limited to, chronic obstructive pulmonary disease, shortness of breath, major depressive disorder, other lack of coordination and pain in the right ankle. Review of Resident #96's MDS dated [DATE] revealed a BIMS score 12 which indicates moderately impaired cognition. Review of Resident #96's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/07/2024 at 8:45 a.m. revealed bilateral bed rails attached to Resident #96's bed. During an interview 10/09/2024 at 09:00 a.m. Resident #96 reported she used her bed rails to assist her in standing and turning. Resident #96 reported the bed rail on the right side of her bed was loose and it made her feel like she was going to fall. Resident #96 reported this was the first time someone had asked her about the bed rails. Resident 101 Review of Resident #101's medical record revealed an admit date of 09/13/2024 with the following diagnoses including, but not limited to, surgical aftercare following surgery of the circulatory system, atherosclerosis of native arteries of extremities with gangrene of left leg, and an open wound to the left foot. Review of Resident #101's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Review of Resident #101's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 8:55 a.m. revealed Resident #101 in bed with bed rails x 2 in the raised position at the head of the bed. During an interview on 10/06/2024 at 8:55 a.m., Resident #101 reported she used the bed rails sometimes to help her change positions in bed. An observation on 10/08/2024 at 10:00 a.m. revealed Resident #101 in bed with bed rails x 2 in the raised position at the head of the bed. Resident #104 Review of Resident #104's medical record had a re-admit date of 07/16/2024 with the following diagnoses including, but not limited to, orthopedic conditions, hypertension, depression, and psychotic disorder. Review of Resident #104's MDS dated [DATE] revealed a BIMS of 3 indicating severely impaired cognition. Review of Resident #104's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. An observation on 10/06/2024 at 2:08 p.m. revealed Resident #104 was in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/07/2024 at 2:34 p.m. revealed Resident #104 was awake in bed with bed rails x 2 in the raised position at the head of the bed. An observation on 10/08/2024 at 8:12 a.m. revealed Resident #104 awake in bed with bed rails x 2 in the raised position at the head of the bed. Resident #106 Review of Resident #106's medical record revealed the following diagnoses including, but not limited to, encounter for orthopedic after care following surgical amputation, muscle weakness, diabetes type 2 and chronic kidney disease. Review of Resident #106's MDS dated [DATE] revealed a BIMS score of 15 which indicating intact cognition. Review of Resident #106's medical record failed to reveal an informed consent was obtained from the resident or the resident's representative prior to installation of the bed rails and failed to reveal an entrapment assessment had been completed. During an observation on 10/07/2024 at 08:30 a.m. revealed Resident #106 had bilateral bed rails attached to his bed. During an interview on 10/08/2024 at 3:14 p.m. S3 DON (Director of Nursing) confirmed Resident #10, #18, #20, #24, #30, #36, #51, #53, #57, #66, #75, #96, #101, #104, #106 did not have a consent for the use of bed rails. During an interview on 10/09/2024 at 9:55 a.m. S2 Corporate Nurse confirmed the facility did not have consents signed for the use of bedrails and resident assessments for entrapment had not been completed correctly.

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by 1) having dirty equipment, and food preparation items used to prepare and/or distribute resident meals in the kitchen, 2) Resident meal plates and saucers stored in an upright position, and 3) the flour scoop was left inside the flour storage container. Findings: Observation of the kitchen on 10/06/2024 at 8:00 a.m. with S4 Morning Cook, revealed the following: 1) The large upright mixer was covered with crumbs and white powder. 2) The oven/warmer had dried food spills and streaks running down the front. 3) Resident meal plates and saucers were stored in an upright position. 4) Plate lids on the meal serving line had food crumbs inside the covers/lids and dried food particles on the serving plates. 5) The flour scoop left inside the flour storage container. During an interview on 10/06/2024 at 10:30 a.m. S5 Dietary Manager acknowledged the dirty kitchen equipment, incorrect plate storage, and storage of the flour scoop in the flour container was a problem that had to be corrected.

Based on record review, observation and interviews the facility failed to ensure it was clinically appropriate for a resident to self-administer medications for 1 (Resident #1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This deficient practice had the potential to affect any of the 117 residents residing in the facility according to the 03/04/2024 Resident Census List provided by the facility. Findings: Review of facility Self-Administration of Medication policy dated 11/17/1994 revealed in part: A resident will be allowed to self-administer medications only if: a. the attending physician writes or gives a verbal order that the resident may keep a medication at bedside for the purpose of self-administration. AND b. the resident has been determined by the interdisciplinary care team to be cognitively, physically, and visually able to self-administer medications, therefore clinically appropriate, and is routinely monitored as to whether the resident continues to be capable and/or still taking medications as ordered. Review of resident #1's medical record revealed an admit date of 02/02/2023 with diagnoses that include Chronic obstructive pulmonary disease, Pleural effusion, acute on chronic diastolic congestive heart failure, hereditary and idiopathic neuropathy, Chronic respiratory failure, abnormalities of gait and mobility, depression, essential hypertension, type 2 diabetes mellitus with diabetic neuropathy, difficulty in walking, need for assistance with personal care, edema, osteoporosis without current pathological fracture, pain, dependence on supplemental oxygen. Review of resident #1's Physician orders revealed an order dated 02/25/2024 for Ipratropium 0.5 mg (milligram)-Albuterol 3 mg (2.5 mg base)/3 ml (milliliters) nebulization solution: give 3 mg inhalation four times daily: document pulse, record the number of treatment minutes, and document toleration. Review of resident #1's Physician orders failed to reveal an order for resident #1 to self-administer medication or keep medications at the bedside. Review of resident #1's medical record failed to reveal a consent for resident #1 to self-administer medications. Review of resident #1's MDS (Minimum Data Set) dated 02/15/2024 revealed in part: Cognitive: BIMS (brief interview for mental status)=13-cognitively intact. During an interview on 03/05/2024 at 9:00 a.m. resident #1 reported the nurse leaves her breathing treatment medicines in her bedside table and she takes them when she feels like it. During an observation on 03/05/2024 at 9:00 a.m. resident #1 pointed out her inhalation medications in her unlocked bedside table drawer. During an interview on 03/06/2024 at 3:30 p.m. S1 DON (Director of Nursing) confirmed the facility did not have any residents in the facility with orders to keep medications at the bedside and self-administer the medications. S1 DON acknowledged resident #1 should not have medications at the bedside and all medications should have been administered by resident #1's nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the comprehensive care plan had been implemented for 1 (#6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility failed to ensure the hospice care plan had been implemented for Resident #6 by failing to ensure hospice had been notified of Resident #6's 02/07/2024 fall. Findings: Review of Resident #6's medical record revealed Resident #6 was originally admitted to the facility on [DATE] and had diagnoses that included, in part, unspecified dementia, senile degeneration of brain, cognitive communication deficit, muscle wasting and atrophy of right and left thigh and right and left lower leg, anemia, history of falling, difficulty in walking, unsteadiness on feet, vascular dementia, and essential hypertension. Review of physician orders revealed a 01/13/2024 order for Do not resuscitate. Admit to _______ Hospice. Do not call 911. Call ________ Hospice with any questions or concerns. D/C (discontinue) skilled therapy, future appointments, and lab work per Dr. (Doctor) ____. Review of 01/24/2024 Significant Change MDS (Minimum Data Set) revealed Resident #6 had severe cognitive impairment, never/rarely made decisions and had short and long term memory problem. Review of Resident #6's Care Plan revealed: Receiving hospice care with interventions that included, in part, comfort measures as needed and notify physician and hospice of any changes in resident. Review of Resident #6's Incident Report dated/timed 02/07/2024 at 11:00 a.m. revealed Resident #6 was in the dining area trying to stand up and walk and had a fall with multiple staff as witnesses and had no apparent injuries Physician and family notified. Further review of the Incident Report failed to reveal hospice had been notified of the 02/07/2024 fall. Review of 02/07/2024 at 11:19 a.m. progress note indicated .was trying to walk without assistance, he stood up from his wheelchair and was seen .falling backwards very slowly.Supervisor was notified, daughter notified MD (Medical Doctor) notified. Further review of the progress note failed to reveal hospice had been notified of the 02/07/2024 fall. During an interview on 03/06/2024 at 10:35 a.m. S4 Hospice RN (Registered Nurse) reported she had not been made aware of Resident #6's 02/07/2024 fall. During an interview on 03/06/2024 at 2:15 p.m. S3 LPN (Licensed Practical Nurse) reported she could not verify hospice had been contacted regarding Resident #6's 02/07/2024 fall. During an interview on 03/06/2024 at 2:30 p.m. S2 ADON (Assistant Director of Nursing) reported after review of Resident #6's medical record no evidence was found that hospice had been notified of Resident #6's 02/07/2024 fall.

Based on observations, record reviews, and interviews the facility failed to ensure the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident for 1 resident (#43) of 1 resident investigated for choices. Findings: Review of Resident #43's MDS (Minimum Data Set) dated 07/12/2023 revealed Resident #43 had a BIMS (Brief Interview for Mental Status) of 15 which indicated cognitively intact. An observation on 09/11/2023 at 9:15 a.m. revealed feces like substance on the wall in two places in Resident #43s room. Further observation at that time revealed dark brown debris on Resident #43's roommate's bedside rail, his roommate's bed remote, and on the shared air conditioner unit in Resident #43's room. During an interview on 09/11/2023 at 1:35 p.m. Resident #43 reported his roommate plays in his feces, throws feces at him and on the walls. Resident #43 reported feces gets everywhere. Resident #43 reported staff had been aware of his roommate's behaviors for six to seven months. Resident #43 further reported he had to leave the room to eat at mealtimes because he can't stand to eat when his room has feces all in it. Resident #43 reported his roommate laughed and cursed at him when he fell out of his wheelchair this morning. Resident #43 indicated he wanted his roommate moved to another room. An observation on 09/11/2023 1:43 p.m. revealed three brown spots of debris on the shared air conditioner unit in Resident #43's room. During an interview on 09/11/2023 at 3:10 p.m. S3 CNA (Certified Nursing Assistant) reported Resident #43's roommate had been putting feces everywhere in their room. S3 CNA further reported Resident #43's roommate would will put feces in his own meal tray, on his own bed, and on the wall in their room. During an interview on 09/12/2023 at 2:18 p.m. S4 CNA reported Resident #43's roommate will take his poop and throw it on the wall and smear it everywhere. S4 CNA reported the CNAs and LPNs (Licensed Practical Nurses) are aware of Resident #43's roommate's behaviors and Resident #43 complains about it all the time. S4 CNA further reported the brown spots on Resident #43's roommate's bedrails, bed remote, and on the shared air conditioner were probably feces. During an interview on 09/13/2023 at 3:00 p.m. S2 DON (Director of Nursing) verified there was not a grievance report generated regarding Resident #43's complaints of his roommate throwing feces in his room. During an interview on 09/13/2023 at 12:40 p.m. S8 LPN (Licensed Practical Nurse) reported Resident #43 was cursed out by his roommate in June. S8 LPN further reported Resident #43's roommate had smeared feces on the wall and on his sheets a couple of times to her knowledge. During an interview on 09/13/2023 at 4:00 p.m. S1 Administrator acknowledged there was not a grievance report generated regarding Resident #43's complaints of his roommate throwing feces in his room.

Based on record review, observations, and interviews the facility failed to ensure residents who were unable to complete Activities of Daily Living (ADLs) received the necessary services to maintain proper grooming and hygiene for 1 (#107) of 3 (#80, #107, #110) residents reviewed for ADLs. The facility failed to ensure Resident #107 received nail care. Findings: Review of facility's Nail Care Policy and Procedure dated 10/24/2022 revealed in part: Policy: All residents will have nails cleaned and trimmed once weekly or as needed per resident request. Review of Resident #107's medical record revealed Resident #107 had an admission date of 08/29/2022 with a diagnosis of Type 2 diabetes mellitus, without complications. Review of physician's orders for Resident #107 revealed an order dated 09/23/2022, which read; assess/trim fingernails and toenails monthly. Further review of Resident #107's physician orders revealed an order dated 04/03/2023, which read; please consult Dr. ________ for the treatment of long, painful toenails. Review of Resident #107's Quarterly MDS (Minimum Data Set) dated 09/04/2023 revealed Resident #107 had a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition. Further review of the 09/04/2023 Quarterly MDS revealed Resident #107 required extensive assistance with personal hygiene. Review of Resident #107's current Care Plan revealed Resident #107 requires assistance from staff with grooming and personal hygiene. An observation on 09/11/23 at 9:30 a.m. revealed Resident #107's toenails were long and had grown up over the top of his toes. Observation revealed Resident #107's right big toenail had broken off and was bleeding. Further observation revealed the top of his left foot had scratch marks, which were bleeding. During an interview on 09/11/2023 at 9:30 a.m., Resident #107 reported my toenails are way longer than I want them to be. During an interview on 09/11/23 at 2:30 p.m., Resident #107 reported the CNA (Certified Nursing Assistant) found the big toenail that had broken off in his bed this morning. An observation on 09/11/23 at 2:35 p.m. revealed Resident #107's toenails were long and had dried blood on the right big toenail bed. During an interview on 09/12/23 at 2:20 p.m., Resident #107 reported no one had looked at his toenails. Resident #107's son was present during the interview and reported a podiatrist is supposed to cut them but the podiatrist had only seen Resident #107 once. During an interview on 09/12/23 at 2:49 p.m., S9CNA reported she has been employed here for 3 weeks and acknowledged she had not clipped Resident #107's toenails. During an observation on 09/12/23 at 3:20 p.m. S5LPN (Licensed Practical Nurse) acknowledged the scratches on the top of Resident #107's right foot and the left big toenail which had broken off. S5LPN further acknowledged Resident #107's toenails needed to be trimmed and had not been.

Based on record reviews and interviews the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 2 of 24 weekend days. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 2 2023 (January 1 - March 31) revealed the submitted weekend staffing data was excessively low. Review of the facility staffing pattern reports for weekends form FY Quarter 1 2023 revealed the facility provided 259.19 hours on 02/12/2023 and were required to provide 267.9 hours. Further review revealed the facility provided 233.45 hours on 02/19/2023 and were required to provide 263.2 hours. During an interview on 09/11/2023 at 3:00 p.m. S2 DON (Director of Nursing) reviewed the facility staffing pattern reports for weekends from FY Quarter 2 2023 and acknowledged the facility did not provide the minimum hours required on 02/12/2023 and 02/19/2023. During an interview on 09/13/2023 at 1:50 p.m. S1 Administrator reviewed the facility staffing pattern reports for weekends from FY Quarter 2 2023 and acknowledged the facility did not provide the minimum hours required on 02/12/2023 and 02/19/2023.

Based on observations, interviews, and record reviews the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure the physician was notified of behaviors exhibited by 1 resident (#96) of 1 resident investigated for behaviors. Findings: Review of the facility's policy for Behavior and Side Effects of Psychoactive Medications, Monitoring of Policy and Procedure with an effective date of 05/22/2017 revealed: Definitions .distressed behavior is behavior that reflects individual discomfort or emotional strain. It may Present as crying apathetic or withdrawn behavior, or as verbal or physical actions such as: pacing, cursing, hitting, pushing, scratching, tearing things, or grabbing others, etc. Procedure: .6. The nurse is to report any increase or new onset of distressed behavior and/or side effects to the attending physician, DON (Director of Nursing) and SSD (Social Services Director). Review of Resident #96's medical record revealed an admit date of 05/14/2023 with diagnoses including but not limited to cerebral infarction due to unspecified occlusion or stenosis of cerebral artery and unspecified intellectual disabilities. Review of Resident #96's most recent MDS (Minimum Data Set) dated 08/30/2023 revealed a BIMS (Brief Interview for Mental Status) of 11 indicating moderately impaired cognition. Further review of Resident #96's MDS revealed Resident #96 was assessed as not having behaviors, Resident #96 required extensive assistance with toileting and was always incontinent of bowel and bladder. Review of Resident #96's comprehensive care plan revealed a problem of Resident #96 exhibited behaviors with a start date of 06/30/2023. Resident #96's behavior problem included smearing feces on the floor and cursing staff. Further review of Resident #96's care plan for behavior problem included the approaches of monitoring and documenting behaviors as well as notifying the MD (Medical Doctor) and family of behaviors. Review of Resident #96's nurse's notes for the past 6 months included a behavior note dated 06/30/23 that indicated Resident #96 was upset due to not wanting to get up and smeared feces on the floor and cursed his roommate. Further review of Resident #96's nurse's notes included further behavior notes dated 08/30/2023 that indicated Resident #96 played in his feces and smeared it all over his bed linens, as well as a behavior note dated 09/06/2023 that indicated Resident #96 had feces like substance under their fingernails and had smeared it all over his bed linens. Review of Resident #96's doctor's progress notes for the past 4 months revealed no documentation of Resident #96's behaviors regarding smearing feces. An observation on 09/11/2023 at 9:15 a.m. revealed feces like substance on the wall in two places in Resident #96's room. Further observation at that time revealed dark brown debris on Resident #96's bedside rail, Resident #96's bed remote, and on the air conditioner unit in the shared room of Resident #96 and Resident #43. An observation on 09/11/23 1:43 p.m. revealed three brown spots of debris on the air conditioner unit in Resident #96 and Resident #43's shared room. During an interview on 09/11/2023 at 3:10 p.m. S3 CNA (Certified Nursing Assistant) reported Resident #96 had been putting feces everywhere in his room. Further reported Resident #96 will put it in his meal tray, his bed, and on the wall. During an interview on 09/12/2023 at 2:18 p.m. S4 CNA reported Resident #96 will take his poop and throw it on the wall and smear it everywhere. S4 CNA reported the CNAs and LPNs (Licensed Practical Nurses) are aware of Resident #96's behaviors and Resident #96's roommate Resident #43 complains about it all the time. S4 CNA further reported the brown spots on Resident #96's bedrails, bed remote, and on the air conditioner were probably feces. During an interview on 09/13/2023 at 9:10 a.m. S8 LPN reported Resident #96 played in his feces when he was mad and smeared it on things. S8 LPN reported Resident #96's roommate and the CNAs would report the behavior to her and she would document it. S8 LPN reported she had not notified the doctor of Resident #96's behavior. S8 LPN further stated S2 DON (Director of Nursing) was aware of Resident #96's behavior. During an interview on 09/13/23 at 9:25 a.m. S2 DON reported she was aware Resident #96 would smear feces on things when he was mad. S2 DON reported the doctor would be notified of such resident behaviors. S2 DON reviewed Resident #96's medical record and confirmed there was not documentation of the doctor being notified of Resident #96's behavior of smearing his feces on things. During an interview on 09/13/23 at 2:08 p.m. S10 Social Services reported the DON usually notified S11 Admissions about resident behaviors and S11 Admissions would notify her. S10 Social services reported she had not been notified about Resident #96 having any behaviors. During an interview on 09/13/23 at 2:10 p.m. S11 Admissions confirmed she would be notified of residents with behaviors and would assist with expediting any admissions to behavioral facilities. S11 Admissions reported she had not been notified of Resident #96 having any behaviors until today.

Based on observations, interviews, and record reviews the facility failed to ensure all patient care equipment was maintained in safe operating condition for 1 resident (#43) out of 101 residents with mobility in a chair all or most of the time according to the Resident Census and Condition of Residents dated 09/11/2023. The facility failed to ensure Resident #43's wheelchair locked properly. Findings: Review of Resident #43's MDS (Minimum Data Set) dated 07/12/2023 revealed Resident #43 had a BIMS (Brief Interview for Mental Status) of 15 which indicated cognitively intact. Further review of Resident #43's 01/12/2023 MDS revealed Resident #43 required limited assistance with one person for bed mobility, transfers, and toilet use. Review of Resident #43's comprehensive care plan revealed the following problems of Resident #43 used his wheelchair for mobility and Resident #43 was at risk for falls both with a start date of 01/18/2023. Review of the facility incident log for the past 120 days revealed Resident #43 had an unobserved fall on 09/11/2023 in his room which resulted in a skin tear. Review of Resident #43's nurse's note dated 09/11/2023 at 6:41 a.m. indicated Resident #43 reported when he was getting up and reached out to get in his chair the brakes were not locked and/or don't work and he fell. Further review revealed Resident #43's assessment revealed a long superficial scrape on his back. During an interview on 09/11/2023 at 1:50 p.m. Resident #43 reported he fell while transferring from the bed to the wheelchair without injury. Resident #43 further reported the locks on his wheelchair were broken and were supposed to be fixed but had not been. Resident #43 reported he told someone at the nurse's station about the wheelchair locks about 6 weeks ago. Observation on 09/11/2023 at 1:55 p.m. revealed the left lock on Resident #43's wheelchair was loose, jiggled, and did not lock. Observation on 09/12/2023 at 10:28 a.m. revealed the left lock on Resident #43's wheelchair continued loose, jiggled, and did not lock. During an observation on 09/12/2023 at 2:44 p.m. with S9 CNA (Certified Nursing Assistant), S9 CNA confirmed the left lock on Resident #43's wheelchair continued loose, jiggled, and did not lock. S9 CNA further reported she had not been aware Resident #43's wheelchair lock was broken. Observation on 09/13/23 at 11:45 a.m. revealed the left lock on Resident #43's wheelchair continued loose, jiggled, and did not lock. During an interview on 09/13/2023 at 12:05 p.m. Resident #43 reported a nurse looked at his wheelchair lock and reported to him someone would be down to look at it. During an observation on 09/13/23 at 12:40 p.m. with S2 DON (Director of Nursing), S2 DON confirmed the left lock on Resident #43's wheelchair continued loose, jiggled, and did not lock. S2 DON further reported Resident #43's wheelchair lock should have been fixed the same day as he reported it and it was not.

Based on interview and record reviews the Facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 1 of 28 weekend days. Findings: Review of the Facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 1 2023 (October 1-December 31) revealed the submitted weekend staffing data was excessively low. Review of Facility's Staffing Pattern forms for weekends from Fiscal Year Quarter 1 revealed the Facility provided 246 hours on 10/16/2022 and were required to provide 277 hours. During an interview on 05/16/2023 at 2:30 p.m. S1 Corporate Nurse confirmed the facility did not provide the minimum required hours on 10/16/2022 and should have.

Based on observation, record reviews and interview the facility failed to ensure respiratory care was provided consistent with professional standards of practice by not having a physician order for oxygen therapy when a resident had been receiving oxygen for several days. Findings: Review of resident #445 clinical records revealed she was admitted to this facility 10/14/2022 from an acute care hospital after a fall at home that resulted in multiple fractures. Observation on 10/17/2022 at 10:58 a.m. revealed resident #445 was receiving oxygen by nasal cannula. Review of resident #445's clinical records failed to reveal any documentation for oxygen therapy, including Physician Orders or a Baseline Plan of Care. Review of the facilities Oxygen Administration Policy and Procedure revealed in part - Purpose: To administer oxygen to the resident when insufficient oxygen is being carried by the blood to the tissues. Policy: Oxygen Administration will be performed as ordered by the physician. Procedure: 1. Check Physician's Order for liter flow and method of administration. 11. Monitor resident's response to therapy with pulse oximetry as necessary. During an interview on 10/19/2022 at 7:50 a.m.S1 DON (Director of Nursing) reported if resident # 445 has oxygen she should have had a Physician order for the oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure resident assessments were transmitted within the required timeframe for 6 (#1, #2, #3, #4, #5, #6 ) residents of 6 (#1, #2, #3, #4, #5, #6) residents reviewed for assessments out of a total of 45 sampled residents. Findings: Review of Resident #1's MDS (Minimum Data Set) assessments revealed a Discharge MDS dated [DATE] with a status of open. Review of Resident #2's MDS assessments revealed a Discharge MDS dated [DATE] with a status of open. Review of Resident #3's MDS assessments revealed a Discharge MDS dated [DATE] with a status of open. Review of Resident #4's MDS assessments revealed a Yearly MDS dated [DATE] with a status of open. Review of Resident #5's MDS assessments revealed a Yearly MDS dated [DATE] with a status of closed. Review of Resident #6's MDS assessments revealed a Quarterly MDS dated [DATE] with a status of open. During an interview on 10/18/2022 at 1:08 p.m. S3 MDS Nurse reported Resident #1, #2, #3, #4, #5, and #6's MDS assessments had not been transmitted to CMS (Centers for Medicare and Medicaid Services) and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (#15, #41) residents out of a total sample of 45. The facility failed to ensure: 1. Resident #15's Keppra and Dilantin levels were obtained as ordered; 2. Resident #41's pulse was monitored prior to administration of Digoxin. Findings: 1. Review of Resident #15's medical record revealed Resident #15 was originally admitted to the facility on [DATE] and had diagnoses that included, in part, Seizures, Essential Hypertension, and Unspecified Psychosis. Review of physician orders revealed: 12/17/20 order for Keppra and Dilantin (phenytoin) Q (every) 3 months-Mar/Jun/Sep/Dec Review of care plan revealed: At risk for injury related to seizure disorder with approaches that included: administer anticonvulsant medication as ordered, labs as ordered with results to MD (medical doctor). Resident is prescribed Keppra. Resident is prescribed Dilantin. Review of Resident #15's lab failed to reveal any Keppra level was obtained in 2022 until 7/22/2022. Further review of Resident #15's lab failed to reveal any Phenytoin level was obtained between 1/31/2022 and 7/22/2022. During an interview on 10/19/2022 at 4:40 p.m. S1 DON (Director of Nursing) reported she had reviewed Resident #15's lab and the phenytoin level had not been obtained between 1/31/2022 and 7/22/2022 and should have been. S1 DON further reported a Keppra level had not been obtained in 2022 until 7/22/2022 and should have been. 2. Review of Resident #41's medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses, in part, heart failure, type 2 diabetes, and unspecified cerebrovascular disease affecting left non-dominant side. Review of Resident #41's current physician orders revealed a 10/18/2022 order for Digoxin 125 mcg (microgram) tablet - give 1 tablet po (by mouth) qd (once daily). Review of Resident #41's Care Plan revealed: A Fib (Atrial fibrillation) Digoxin with interventions including administer meds as ordered, need labs drawn as ordered, I need my vital signs monitored as ordered and as needed. Review of Resident #41's September 2022 MAR (Medication Administration Record) revealed Digoxin 125mg(milligram) tablet was administered 9/1/2022 to 9/30/2022 with no recorded pulse rate. Review of Resident #41's October 2022 MAR revealed: -10/1/2022 to 10/7/2022 Digoxin 125mg tablet was administered with no pulse rate recorded. -10/8/2022 to 10/18/2022 Digoxin 125mg tablet was administered 10/8/2022 to 10/18/2022 with O2 sat recorded but no pulse rate. During an interview on 10/19/2022 at 11:40 a.m. S2 Corporate Nurse and S1 DON reviewed September 2022 and October 2022 MARs and reported the pulse rate had not been monitored prior to administration of Digoxin for Resident #41 and should have been.

Based on observations, record reviews and interviews the facility failed to maintain a medication error rate of less than 5%. A total of 5 residents were observed during the facility's medication pass administered by three LPNs (Licensed Practical Nurse) on 10/18/2022. A total of 27 opportunities were observed which included 3 medication errors with three residents (#14, #100, #296), for a medication error rate of 11.11%. Resident #126's Latanoprost 0.005 % eye drops was not being administered as ordered. Findings: Resident #14 Observation on 10/18/2022 at 8:00 a.m. during med pass revealed S4 LPN failed to administer Potassium 20 meq (milliequivalent) to resident #14 as ordered. During an interview on 10/18/2022 at 11:00 a.m. S4 LPN confirmed she did not administer resident #14's Potassium 20 meq at 08:00 a.m. as ordered. Review of Resident #14's October 2022 Physician Order in part revealed order date of 9/30/2021 Potassium Chloride 20 meq Tablet- Give 1 tablet by mouth daily. Review of Resident #14 Clinical Record revealed diagnosis' that included: Type 2 diabetes, Chronic Kidney Disease Stage 3, Paroxysmal Atrial Fibrillation. Resident #100 Observation on 10/18/2022 at 8:00 a.m. during med pass revealed S4 LPN failed to administer resident #100's Miralax as ordered. During an interview on 10/18/2022 at 10:58 a.m. S4 LPN confirmed she did not administer Miralax to resident #100. S4 LPN confirmed the Miralax for resident #100 is ordered to be given daily. Review of resident #100's October 2022 Physician Order in part revealed an order dated 8/07/2020 Miralax (Polyethylene Glycol) -give 17 gm (gram) with 8 oz (ounce) H2O (water) or juice by mouth daily. Review of Resident #100 clinical records revealed diagnoses that include COPD (chronic obstructive pulmonary disease), Constipation, GERD (gastroesophageal reflux disease). Review of Resident # 296 Observation on 10/18/2022 at 8:00 a.m. during med pass revealed S5 LPN failed to administer Dorzolamide/Timolol eye drops to resident #296 as ordered. During an interview on 10/18/2022 at 10:53 a.m. S4 LPN reported she will give resident #296 Dorzolamide/Timolol eye drops after lunch in his room. S4 LPN reported she administers the drops after lunch each day. S4 LPN confirmed resident #296's Dorzolamide/Timolol eye drops should be administered at 8:00 a.m. and 4:00 p.m. Review of resident #296's October 2022 MAR (medication administration record) revealed Dorzolamide/Timolol ophthalmic solution-instill 1 drop into both eyes BID (twice a day) at 8:00 a.m.and 4:00 p.m. Review of resident #296's October 2022 Physician Orders in part revealed an order dated 9/30/2022 Dorzolamide/Timolol ophthalmic solution-instill 1 drop into both eyes BID. Review of resident #296's clinical records revealed diagnoses that included: Essential Hypertension, CAD (Coronary Artery Disease), DM (Diabetes Mellitus), Hyperlipidemia, and Dementia. Resident #126 During an interview on 10/17/2022 at 12:29 p.m. resident #126 reported she was getting several eye drops before she was admitted to this facility. She reported since she arrived here she has not gotten any eye drops. Review of resident #126 Physician Orders revealed the following orders for eye drops. 9/9/2022 Dorzolamide 22.3 mg (milligram) -timolol 6.8 mg/ml eye drops instill one drop into each bid (twice a day). 9/9/2022 Latanoprost 0.005 % eye drops instill one drop into both eyes at bedtime. Observation on 10/19/2022 at 9:00 a.m. of the medicine cart with S6 LPN failed to reveal Latanoprost drops on the med cart to be administered. S6 LPN reported the eye drops should be on the cart to be administered. Observation of the Med Storage room by S6 LPN failed to reveal Latanoprost eye drops for resident #126. During an interview on 10/19/2022 at 9:30 a.m. S6 LPN reported the Latanoprost eye drops should have been ordered and available to be administered to resident #126.