**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 4 (#11, #20, #24, and #29) of 5 (#11, #15, #20, #24 and #29) residents reviewed for restraints. The facility failed to 1) obtain a consent, 2) have a physician's order and 3) failed to appropriately assess residents prior to placing the bolsters on the bed. Findings: Review of the facility's Respect and Dignity Policies and Procedures dated 03/02/2023 revealed ____ ____ Nursing Home will ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Should ____ ____ staff decide to use a restraint, it must be the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. It is our intent at ____ ____ for each resident to attain and maintain his/her highest practical well-being in an environment that: Prohibits the use of physical restraints for discipline or convenience; Prohibits the use of physical restraint to unnecessarily inhibit a resident's freedom of movement or activity; and limits physical restraint use to circumstances in which the resident has medical symptoms that may warrant the use of restraints. ____ ____ Nursing Home staff will document the symptoms being treated, and a physician's order for the use of the specific type of restraint will be obtained. A resident will be appropriately assessed prior to the use of any restraint. The care plan interdisciplinary team will be involved and documentation of the medical symptoms and use of the physical restraint for the least amount of time possible will be noted. Ongoing re-evaluation is necessary to be in compliance with regulatory requirements. Resident 20 Review of the medical record for resident #20 revealed an admission date of 07/05/2023. Resident #20 had diagnoses including diabetes mellitus, osteomyelitis, open angle glaucoma, gastrostomy, aphasia, metabolic encephalopathy, peripheral vascular disease, pain, embolism, and heart failure. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive skills for daily decision making, was totally dependent on staff and required two person assistance with bed mobility and transfers. Observations of resident #20 on 01/27/2025 at 8:35 a.m., 01/27/2025 at 3:20 p.m., and on 01/28/2025 at 10:10 a.m., revealed the resident was lying in the bed with bilateral bolsters attached to the bottom half of the bed. Review of the care plan revealed resident #20 had a potential for falls due to decreased mobility and she had a roll control bolster on the bed, monitor every 2 hours with incontinent checks and turning and as needed contact. Review of the medical record revealed no documented evidence of an assessment prior to the use of roll control bolsters, no consent from the resident or the Responsible Party and there was no physician's order for the use of the roll control bolsters. An interview on 01/28/2025 at 12:00 p.m. with S1Administrator confirmed the facility failed to obtain a consent and a physician's order prior to the use of the bolsters, and they failed to assess resident #20 prior to the use of bolsters. Resident 24 Review of the medical record for resident #24 revealed an admission date of 08/30/2023. Resident #24 had diagnoses including bradycardia, lack of coordination, cognitive communication deficit, pain, Parkinson's disease, and macular degeneration. Review of the Quarterly MDS assessment dated [DATE] revealed the facility was unable to determine resident #24's Brief Interview for Mental Status (BIMS) score due to cognitive impairment. Resident #24 required extensive assistance with bed mobility and was totally dependent on staff with transfers. Observations of resident #24 on 01/27/2025 at 9:15 a.m., and 01/28/2025 at 9:00 a.m. revealed the resident was observed lying in the bed with bilateral bolsters attached to the bottom half of the bed. Review of the current care plan revealed resident #24 had the potential for falls and an intervention was noted for a roll control bolster, monitor every 2 hours with incontinent checks and turning and as needed. Review of the medical record revealed no documented evidence of an assessment prior to the use of roll control bolsters, no consent from the resident or the Responsible Party and there was no physician's order for the use of the roll control bolsters. An interview on 01/28/2025 at 12:00 p.m. with S1Administrator confirmed the facility failed to obtain a consent and a physician's order prior to the use of the bolsters, and they failed to assess resident #20 prior to the use of bolsters. Resident #11 Review of resident #11's record revealed an admission date of 08/15/2022 with diagnoses including Alzheimer's disease, wedge compression fracture of thoracic 11 and 12 vertebra, paroxysmal atrial fibrillation, glaucoma, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, unspecified protein calorie malnutrition, displaced fracture of base of neck of left femur, presence of left artificial hip joint, and osteoarthritis. Review of resident #11's January 2025 Physician's Orders revealed an order dated 07/21/2024 for quarter side rails on each side of bed up at all times as enabler in turning/repositioning. Review of the Significant Change/5 day MDS assessment dated [DATE] revealed a BIMS score of 99 indicating unable to determine. Further review of the MDS revealed resident had severely impaired cognitive skills for daily decision making and dependent on staff for activities of daily living. Review of resident #11's current care plan revealed a need for bed rails related to a history of falls. Observations of resident #11 on 01/27/2025 at 9:05 a.m., 01/27/2025 at 3:24 p.m., and 01/28/2025 at 8:10 a.m. revealed resident was lying in bed with bilateral bolsters attached to the bottom half of the bed. Review of the medical record revealed no documented evidence of an asessment prior to the use of roll control bolsters, no consent from the resident or the responsible party, and no physician's order for the use of bed bolsters for resident #11. An interview on 01/28/2025 at 3:55 p.m. with S1Administrator confirmed the facility failed to obtain a consent and a physician's order prior to the use of the bolsters, and they failed to assess resident #11 prior to the use of bolsters. Resident #29 Review of resident #29's record revealed an admission date of 03/14/2023 with diagnoses including pressure ulcer of sacral region stage 3, unspecified dementia unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, Alzheimer's disease, atrial fibrillation, other seizures, type 2 diabetes mellitus, and gastrostomy status, Review of resident #29's Quarterly MDS assessment dated [DATE] revealed unable to determine a BIMS score due to cognitive impairment. Further review of the MDS revealed resident dependent on staff for activities of daily living. Observations of resident #29 on 01/27/2025 at 8:50 a.m. and 01/28/2025 at 8:20 a.m. revealed resident was lying in bed with bilateral bed bolsters in place Review of the medical record revealed no documented evidence of an assessment prior to the use of roll control bolsters, no consent from the resident or the responsible party, and there was no orders for the use of the roll control bolsters. An interview on 01/28/2025 at 3:55 p.m. with S1Administrator confirmed the facility failed to obtain a consent and a physician's order prior to the use of the bolsters, and they failed to assess resident #29 prior to the use of bolsters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident was free of accident hazards as is possible by failing to ensure appropriate interventions were attempted after each fall for 1 (#11) of 1 residents sampled for falls. Findings: Review of resident #11's medical record revealed an admission date of 08/15/2022 with diagnoses including Alzheimer's disease, wedge compression fracture of Thoracic 11 and 12 vertebra, paroxysmal atrial fibrillation, glaucoma, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, unspecified protein calorie malnutrition, displaced fracture of base of neck of left femur, presence of left artificial hip joint, and osteoarthritis. Review of resident #11's January 2025 Physician's Orders revealed an order dated 07/21/2024 for quarter side rails on each side of bed up at all times as enabler in turning/repositioning. Review of resident #11's Significant Change/5 day Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 99 indicating unable to determine. Further review of the MDS revealed resident had severely impaired cognitive skills for daily decision making and dependent on staff for activities of daily living. Review of resident #11's Incident/Accident report dated 10/12/2024 revealed resident was ambulating in the front lobby with her walker and fell. Resident reported her feet got tangled in her walker and she fell and hit her head on the floor. Review of resident #11's Incident/Accident report dated 11/12/2024 revealed resident #11 found lying on the floor in her room on right side and had a hematoma to the back of head. Review of resident #11's Incident/Accident report dated 12/15/2024 revealed resident #11 was found on the floor in her room. Resident reported she was going to the bathroom and slipped in her own urine, no complaints of pain at this time. Review of the current care plan for resident #11 revealed she had a potential for falls related to history of fall, right hip replacement, osteoarthritis, dementia with history of behavior disturbance, and depression. Further review of resident's fall care plan revealed the following interventions were implemented for the falls listed as follows: 10/12/2024 intervention- encourage/remind resident when standing to get her balance before moving her feet or her walker; 11/12/2024 intervention- remind to wear well fitted shoes; and 12/15/2024 intervention- therapy to evaluate Review of the Fall Risk Evaluations dated 11/08/2024 and 12/27/2024 revealed resident #11 at risk for falls. An interview on 01/28/2025 at 3:30 p.m. with S2Director of Nursing (DON) confirmed the interventions the facility documented for these falls were not appropriate to help prevent falls for resident #11.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #20 Review of the medical record for resident #20 revealed an admission date of 07/05/2023. Resident #20 had diagnoses including diabetes mellitus, osteomyelitis, open angle glaucoma, gastrostomy, aphasia, metabolic encephalopathy, peripheral vascular disease, pain, embolism, and heart failure. Review of the January 2025 physician's orders for resident #20 revealed an order dated 07/01/2024 for quarter rails on each side of bed up at all times as enabler in turning and repositioning. Review of resident #20's quarterly minimum data [NAME] (MDS) dated [DATE] revealed the resident had severe cognitive skills for daily decision making and was totally dependent on staff and required two person assistance with bed mobility and transfers. On 01/27/2025 at 8:35 a.m., 01/27/2025 at 3:20 p.m., and on 01/28/2025 at 10:10 a.m., resident #20 was observed lying in the bed with bilateral quarter rails raised at the top of the bed. Review of the medical record revealed no documented evidence of the facility assessing the risk for entrapment prior to the installation of bed rails. An interview on 01/28/2025 at 12:00 p.m. with S1Administrator confirmed the facility failed to assess the risk for entrapment prior to the installation of bed rails for resident #20. Based on record reviews, observations, and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to installation for 3 (#11, #15, and #20) of 4 (#11, #15, #20, and #29)residents reviewed for accident hazards. Findings: Review of the facility's Bed Rails and Non-Restraint Measures Policy and Procedures revised date 10/11/2024 revealed: Intent: Prior to the installation of bed rails, ____ _____ Nursing Home will attempt to use alternatives. When alternatives are not adequate to meet the resident's needs, the resident will be assessed for the use of bed rails: which includes a review of risks including entrapment; and informed consent is obtained from the resident or if applicable, the resident representative. Resident #15 Review of resident #15's record revealed an admission date of 09/22/2021 with diagnoses including chronic systolic (congestive) heart failure, hypoxemia, moderate protein-calorie malnutrition, major depressive disorder, dementia in other diseases classified elsewhere unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, mood disturbance, and anxiety. Review of the January 2025 physician's orders for resident #15 revealed an order dated 07/01/2024 for quarter side rails on each side of bed up at all times as enabler for turning/repositioning. Review of resident #15's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive skills for daily decision making and required total assistance with activities of daily living. Observations of resident #15 on 01/27/2025 at 3:05 p.m. and 01/28/2025 at 3:45 p.m. revealed resident lying in bed with quarter bilateral bed rails in place. Review of the current care plan revealed resident #15 needed bed rails related to muscle weakness as an enabler for turning/repositioning within the bed. Review of the medical record revealed no documentation of the facility assessing the risk for entrapment prior to the installation of bed rails for resident #15. An interview on 01/28/2025 at 3:55 p.m. with S1Administrator confirmed the facility failed to assess the risk for entrapment prior to installation of bed rails on resident #15. Resident #11 Review of resident #11's medical record revealed an admission date of 08/15/2022 with diagnoses including Alzheimer's disease, wedge compression fracture of Thoracic 11 and 12 vertebra, paroxysmal atrial fibrillation, glaucoma, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, unspecified protein calorie malnutrition, displaced fracture of base of neck of left femur, presence of left artificial hip joint, and osteoarthritis. Review of resident #11's January 2025 physician's orders revealed an order dated 07/21/2024 for quarter side rails on each side of bed up at all times as enabler in turning/repositioning. Review of the Significant Change/5 day MDS assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 99 indicating unable to determine. Further review of the MDS revealed resident had severely impaired cognitive skills for daily decision making and dependent on staff for activities of daily living. Review of resident #11's current care plan revealed a need for bed rails related to a history of falls. Observations of resident #11 on 01/27/2025 at 9:05 a.m., 01/27/2025 at 3:24 p.m., and 01/28/2025 at 8:10 a.m. revealed resident was lying in bed with quarter bilateral bed rails in the up position. Review of the medical record revealed no documentation of an assessment for the risk of entrapment prior to the installation of bed rails for resident #11. An interview on 01/28/2025 at 3:55 p.m. with S1Administrator confirmed the facility failed to assess the risk for entrapment prior to the installation of bed rails on resident #11.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure each resident's medication regimen was free from unnecessary medications for 1 (#17) of 5 (#11, 14, 17, 26 and 33) residents reviewed for unnecessary medications. The facility failed to have documented evidence of parameters or justification for resident #17's as needed medications administered. Findings: Review of the medical record for sampled resident #17 revealed an admission date of 01/30/2023 with diagnoses including insomnia, hypertension, hyperlipidemia, pain, hypothyroidism, hypokalemia, and heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment for daily decision making and required assistance with activities of daily living. Review of the current care plan revealed resident #17 was at risk for cardiovascular complications related to diagnoses of hypertension and cardiomyopathy. Further review of the care plan revealed the interventions were to obtain and evaluate blood pressure two times a day, notify the physician of changes, monitor the effectiveness of the medications, and to monitor for a headache and dizziness. Review of the physician's orders dated 11/02/2023 revealed an order for Bumetanide 1 milligram (mg) two times a day as needed, and Coreg 12.5 mg every day as needed. Review of the Medication Administration Record (MAR) for December 2023 revealed the resident received Bumetanide 1 mg on 12/07/2023 at 11:37 p.m., 12/08/2023 at 2:16 p.m., and on 12/11/2023 at 3:15 p.m. Further review of the MAR revealed the resident received Coreg 12.5 mg on 12/07/2023 at 11:37 p.m. Review of the record revealed no documented evidence of parameters or justification for the as needed medications administerd to resident #17. On 12/13/2023 at 11:50 a.m. an interview with S6Registered Nurse revealed there was no documentation in the nurses notes or the MAR for the reason or parameters for the as needed medications administered to resident #17. On 12/13/2023 at 1:30 p.m. S2Director of Nursing (DON) was notified that the nurses did not document the justification for the medications administered to resident #17. On 12/13/2023 at 2:30 p.m. an interview with S2DON revealed the facility did not have parameters for when to administer the as needed medications to resident #17. On 12/13/2023 at 3:00 p.m. S1Administrator was notified that resident #17 received as needed medications and there was no justification for the reason the medications were given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #33 Review of the medical record revealed resident #33 was admitted to the facility on [DATE] with diagnoses including in part, Type 2 diabetes with foot ulcer, cerebral vascular disease, left side,peripheral vascular disease, hemiplegia following cerebral infarction. Review of the December 2023 physician's orders revealed in part, the following orders dated 09/29/2023 for accu checks with meals and at bedtime and Humalog 100 unit/milliliter vial per sliding scale. Further review of the Humalog order revealed sliding scale insulin as 151-200 mg/dl (Milligrams per deciliter) =3 units, 201-250 mg/dl=6 units, 251-300 mg/dl=8 units, 301-350=12 units, 351-400 mg/dl=16 units, and greater than 400=20 units. Review of the November 2023 MAR (Medication Administration Record) revealed resident #33 had blood glucose levels of 441 mg/dl on the date of 11/10/2023 at 6:00 a.m., 581 mg/dl on the date of 11/17/2023 at 6:00 a.m. Review of the December 2023 physician's orders revealed there was no documented evidence of parameters to indicate at what level of the blood glucose results the nurse was to report to the physician. Review of the November 2023 MAR revealed resident #33 received Humalog insulin per sliding scale 56 times and 30 times as documented on the December 2023 MAR. Review of the November 2023 and December 2023 MARs and nurse's notes revealed resident #33 had received the Humalog insulin injections, but there was no documented evidence of the insulin injection sites. Further review revealed there was no documented parameters in the physician's orders to indicate when the blood glucose level should be reported to the physician. On 12/13/2023 at 2:20 p.m., S3LPN (Licensed Practical Nurse) was notified of the findings regarding there being no documented evidence on November 2023 and December 2023 MARs of the Humalog insulin sites for resident #33. After completing a review of the MARs, S3LPN confirmed the insulin sites had not been documented on the MARs, after administration. After completing a review of the November 2023 and December 2023 MARs and nurse's notes on 12/13/2023 at 2:30 p.m. with S2DON (Director of Nursing), she confirmed the sites of the insulin injections for resident #33 had not been attached to the medication orders within the special requirements section of the electronic health records and not available for nursing staff documentation. S2DON further confirmed there was no documented evidence in the physician's orders and the facility's standing orders to indicate when the blood glucose level should be reported to the physician. Based on record reviews and interviews, the facility failed to ensure the nursing staff had appropriate competencies and skills sets to provide nursing care and related services to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (#14, #33 ) of 5 (#11, #14, #17, #26, #33) residents investigated for unnecessary medications. The facility failed practice was evidenced by nurses' failing to 1). document injections sites for Insulin and 2). follow parameters for Insulin Sliding Scale. Findings: Review of resident #14's medical record revealed he was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. Review of resident #14's physician order dated 04/22/2022 revealed the following: Monitor and record blood sugar before meals and at bedtime. Notify physician if blood sugar (BS) is <60 or >400. Further review of resident #14's physician order dated 02/21/2023 revealed the following: Humalog 100 Units/Milliliters (ML) Kwikpen administer following Sliding Scale (SS): 0-90 = 0 Units 91-150 = 6 Units 151-200 = 10 Units 201-250 = 12 Units 251-300 = 15 Units >300 = 18 Units Review of resident #14's November 2023 and December 2023 Medication Administration Records (MARs) revealed the nurses failed to document any injection sites (before meals and at HS) for the Humalog Insulin SS that was administered to resident #14 for the months of November and December 2023. Review of resident #14's November 2023 and December 2023 MARs revealed the following: 1). for November 2023, S3Licensed Practical Nurse (LPN) failed to notify resident #14's physician 8 times when his blood sugar was >400; and 2). for December 2023, S3LPN failed to notify resident #14's physician 5 times when his blood sugar was >400. On 12/13/2023 at 2:40 p.m., an interview with S3LPN confirmed she failed to document any of the injection sites for the Humalog Insulin SS that was administered to resident #14 for November and December 2023. S3LPN also confirmed she failed to notify resident #14's physician each time his blood sugar was greater than 400 for November 2023 and December 2023. On 12/13/2023 at 3:30 p.m., S2Director of Nursing (DON) confirmed that the nurses failed to document resident # 14's injection sites for Humalog SS for November 2023 and December 2023. S2DON also confirmed S3LPN failed to follow parameters for Humalog Insulin SS for November and December 2023 as evidenced by no documentation that S3LPN notified resident #14's physician each time his blood sugar was >400.

Based on observations and interviews, the facility failed to ensure drugs and biologicals were stored and labeled properly in accordance with currently accepted professional principles. The facility failed to have multiple use medications and biologicals labeled with the date of opening and stored per professional standards. Findings: On 12/11/2023 at 8:30 a.m., an observation of the Medication Cart A revealed there was one Novolog FlexPen and one Levemir FlexPen. Further observation revealed the FlexPens had been opened and were not labeled with an open date. S5LPN (Licensed Practical Nurse) was present during the observations. S5LPN confirmed the Novolog and Levemir FlexPens (Pre-Filled Insulin Pens) were currently being used for resident #3. She further confirmed they had not been labeled with an opened date. On 12/11/2023 at 12/11/2023 at 8:45 a.m., an observation of the Medication Cart B revealed there were four individual Humalog KwinPens (Pre-Filled Insulin Syringes). Further observation revealed they had been opened and were not labeled with an opened date. S4LPN was present during the observations and confirmed the Humalog KwinPens were currently being used for residents #5, #9, #14, and #33. She further confirmed the prefilled insulin syringes had not been labeled with an opened date. On 12/11/2023 at 9:15 a.m., an observation of the medication room revealed there were 3 vials of Lidocaine 1% and one vial of Lidocaine 2% that was stored inside of a drawer. Further observation revealed the vials had been opened and were not labeled with an opened date. S5LPN was present during the observations. She reported the vials of Lidocaine had previously been used for residents #3, #18, and #24. S5LPN further reported the residents no longer required the medication Further interview with S5LPN revealed that one of the vials of Lidocaine 1% belonged to a resident who was no longer residing in the facility. S5LPN confirmed the vials of Lidocaine should not have been stored in the medication storage room and be available for further resident use. On 12/13/2023 at approximately 2:45 p.m., S2DON was notified of the findings during the observations of Medication Cart A, Medication Cart B, and the medication storage room. S2DON confirmed the resident medications should have been labeled with an opened date and the vial of Lidocaine 1% should have been discarded when the resident was discharged and not be available for further resident use. On 12/13/2023 at 4:15 p.m., S1Administrator was notified of the findings during the observations of Medication Cart A, Medication Cart B, and the medication storage room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the pharmacist failed to identify and report irregularities to the physician and DON (Director of Nursing) for 1 (#5) of 5 (#1, #4, #5, #19, #21) residents reviewed for unnecessary medications. The pharmacist failed to address that the resident was not adequately monitored while receiving an anticoagulant. Findings: Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses include but not limited to the following: essential hypertension, heart disease unspecified, unspecified dementia without behavioral disturbance, memory deficit following subarachnoid hemorrhage, pure hypercholesterolemia and atrial fibrillation/flutter. Review of the November 2022 physician orders revealed an active order Eliquis 2.5 mg (milligram) tablet give one tablet po (by mouth) twice a day that was originally ordered on 08/08/2022. Eliquis is an anticoagulant medication. Review of the August, September, October, and November 2022 EMAR (Electronic Medication Administration Record) revealed Resident #5 received Eliquis 2.5 mg po twice a day as ordered. There was no documentation of monitoring for signs and symptoms of bleeding noted. Further record review revealed there was no documentation for the daily monitoring for signs and symptoms of bleeding. Review of Resident #5's monthly medication regimen review for August, September, and October 2022 completed by the consultant pharmacist revealed there was no recommendation for the monitoring of bleeding related to receiving the anticoagulant medication (Eliquis). On 11/02/2022 at 10:00 a.m. an interview conducted with S2DON(Director of Nursing) was notified of the findings regarding no documentation for the daily monitoring of Resident #5 for signs and symptoms of bleeding. S2DON confirmed there was no documentation of the daily monitoring for signs and symptoms of bleeding. S2DON further confirmed Resident #5 should be monitored for signs and symptoms of bleeding daily while receiving an anticoagulant medication. On 11/02/2022 at 10:05 a.m. an interview conducted with S2DON confirmed that the consultant pharmacist failed to identify that Resident #5 was receiving an anticoagulant medication without being monitored daily bleeding.

Resident #9 Observation on 10/31/2022 at 10:00 a.m. revealed resident #9's oxygen tubing and facemask nebulizer were not dated and were not in the protective bag. The protective bag was dated 07/31/2022. Observation on 11/01/2022 at 9:15 a.m. revealed the oxygen tubing and facemask nebulizer continued with no date or label and not stored in a protective bag. Review of the physician orders for October 2022 revealed the following orders: 02/11/2020 - change oxygen and nebulizer tubing on the 1st and 15th of each month, 07/07/2019 - oxygen therapy at 2 lpm (liters per minute) per mask if oxygen saturation is below 92% as needed for dyspnea related to anxiety and other health related diagnoses, and 05/13/2019 - Ipratropium - albuterol 0.5 - 3 (2.5) milligrams/3 milliliters administer 1 vial per inhalation every 6 hours as needed. Review of the Medication Administration Record for October 2022 revealed the resident received oxygen on 10/30/2022 and 10/31/2022 and the resident received the nebulizer treatment on 10/31/2022. An interview on 11/01/2022 at 12:40 p.m. with S4LPN (Licensed Practical Nurse) confirmed the oxygen tubing and nebulizer were not dated and not in a protective bag. S4LPN confirmed the bag was dated 07/31/2022. During an interview with S2DON (Director of Nursing) on 11/01/2022 at 1:15 p.m., S2DON was notified that the oxygen tubing and nebulizer were not dated and not in a protective bag. During an interview with S1Administrator on 11/02/2022 at 1:00 p.m., S1Administrator was notified that the oxygen tubing and nebulizer were not dated and not in a protective bag. Based on observations, recorded reviews, and interviews, the facility failed to provide necessary care and services that is in accordance with professional standards of practice for 2 (#4 and #9) of 2 residents reviewed for respiratory care. The facility failed to 1) properly change the nasal cannula (#4 and #9) and the nebulizer facemask (#9) and label them with the date it was changed and 2) store the nasal cannula and the nebulizer face mask in plastic bag when not in use per their policy. Findings: Review of the facility policy and procedure for Oxygen/Tubing/Humidifier Tubing Change revealed: All oxygen and nebulizer tubing/equipment will be changed every 14 days - on the 1st and 15th of each month by the infection control nurse. Nurse will date tubing at this time. PRN (when necessary) oxygen/nebulizers are to be changed monthly. Oxygen and nebulizers are to be stored in bag when not in use. Resident #4 On 10/31/2022 at 6:46 a.m. resident #4 stated he uses his oxygen every now and then, only when he needs it. Resident #4 further stated that he last wore oxygen on Saturday night, 10/29/2022, and Sunday night, 10/30/2022. Observation at this time of the oxygen tubing revealed it was lying on the floor with the nasal cannula directly touching the floor. Further observation of the oxygen tubing revealed it was not dated. On 10/31/2022 at 12:43 p.m. review of the physician orders dated 10/21/2022 revealed oxygen via nasal cannula at 2 lpm (liters per minute) every evening. On 11/01/2022 at 8:17 a.m., observation revealed the oxygen tubing continued with no date or label, and not stored in a protective bag. On 11/01/2022 at 12:55 p.m., interview with S5LPN (Licensed Practical Nurse) confirmed the oxygen tubing was not dated, labeled or stored per the facility's policy. On 11/01/2022 at 1:18 p.m., interview with S6LPN revealed she was in charge of changing oxygen tubing monthly. S6LPN confirmed the current oxygen tubing was not stored properly, not in a bag and not labeled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary medication by failing to ensure a resident was adequately monitored for signs and symptoms of bleeding while receiving an anticoagulant medication for 1 (#5) of 5 (#1, #4, #5, #19, #21) sampled residents reviewed for unnecessary medications. Findings: Record review revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included but not limited to the following: essential hypertension, heart disease unspecified, unspecified dementia without behavioral disturbance, memory deficit following subarachnoid hemorrhage, pure hypercholesterolemia and atrial fibrillation/flutter. Review of the physician orders for November 2022 revealed an active order Eliquis 2.5 mg (milligram) tablet give one tablet po (by mouth) twice a day that was originally ordered on 08/08/2022. Eliquis is an anticoagulant medication. Review of the August, September, October, and November 2022 EMAR (Electronic Medication Administration Record) revealed Resident #5 received Eliquis 2.5 mg po twice a day as ordered. There was no documentation of monitoring for signs and symptoms of bleeding noted. Further record review revealed there was no documentation for the daily monitoring for signs and symptoms of bleeding. On 11/02/2022 at 10:00 a.m. an interview conducted with S2DON (Director of Nursing) was notified of the findings regarding no documentation of the daily monitoring of Resident #5 for signs and symptoms of bleeding. S2DON confirmed there was no documentation of the daily monitoring for signs and symptoms of bleeding. S2DON further confirmed Resident #5 should be monitored for signs and symptoms of bleeding daily while receiving an anticoagulant medication.