Based on observation, interview and record review, the facility failed to ensure staff adhered to the facility policy for Self-Administration of Medications, in regard to providing a secure area to store medication and in regard to documenting the frequency of use of a self-administered medication for 1 of 1 applicable Residents (#83) that were deemed appropriate to self administer medications, out of a total sample of 13 residents. Findings include: Resident #83 was admitted to the facility in July 2022 with diagnoses which included hypertension, fractured right femur and chronic obstructive pulmonary disease (COPD). The Resident scored a 15 out of 15 on his/her Brief Interview for Mental Status Exam (BIMS), indicating he/she is cognitively intact. Review of the facility policy, entitled, Self-Administration of Medications, dated 2/2021, included the following: * Self -administered medications are stored in a safe and secure place, which is not accessible by other residents. * If the resident is able and willing to take responsibility for documenting self-administration of medications, the resident is instructed on how to complete a record indicating the administration of the medication. * Nursing staff reviews the Self-Administered Medication Record for each nursing shift, and transfers pertinent information to the medication administration record (MAR), appropriately noting that the doses were self-administered. On 7/20/22 at 7:21 A.M., the surveyor observed a levoalbuterol (medication used for shortness of breath) inhaler resting on Resident #83's overbed table, located next to his/her bed. On 7/20/22 at 1:15 P.M., the surveyor observed a levoalbuterol inhaler resting on top of Resident #83's bed. On 7/21/22 at 7:15 A.M., the surveyor observed a levoalbuterol inhaler resting on the overbed table, next to Resident #83's bed. Review of the physician's order, dated 7/12/22, indicated an order for levoalbuterol 45 micrograms (mcg)/actuation aerosol inhaler, 2 puffs inhalation every 6 hours as needed for shortness of breath, may keep albuterol inhaler at bedside and self-administer. Review of a Self-Administration of Medication tool, electronically signed and dated on 7/20/22, indicated that the interdisciplinary team assessed Resident #83 and determined he/she can leave medications at the bedside and self administer. Review of the MAR, dated July 2022, failed to indicate if staff asked Resident #83 if he/she had any as needed use of his/her levoalbuterol inhaler per the facility policy. During an interview on 7/21/22 at 8:39 AM, Licensed Nurse #1 said that she asks Resident #83 often if he/she has used the inhaler and recalls the Resident saying he/she used it once on Licensed Nurse #1's time. Licensed Nurse #1 said she can't speak for other shifts. Licensed Nurse #1 said that she did not document any as needed usage of the inhaler on the MAR. During an interview on 7/21/22 at 11:00 A.M., the Director of Nursing said that there are cognitively impaired resident's that wander on the unit where Resident #83 resides and all medications must be secured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to prevent 1 Resident (#17) from sustaining a fall, out of a total sample of 13 residents. Findings include: Review of the facility policy titled, Falls and Fall Risk, Managing, dated 12/2018, indicated the following: *The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions. Resident #17 was admitted to the facility in June 2022 with diagnoses that included Alzheimer's Disease and spinal stenosis. Review of Resident #17's most recent Minimum Data Set (MDS) dated [DATE] revealed Resident #17 had a Brief Interview for Mental Status score of 9 out of a possible 15, which indicated he/she has moderate cognitive impairment. The MDS also indicated Resident #17 requires minimal assistance from staff for mobility tasks. Review of Resident #17's fall care plan created on 6/7/22 indicated the following intervention: *Uses 1 assist and gait belt for all ambulation. Use additional assist as needed when Resident is not feeling well, feeling weak or dizzy. Device used for ambulation: Rollator. Review of Resident #17's Activity of Daily Living (ADL) care plan created 6/7/22 indicated the following intervention: *Assist of Resident using 1 staff assist. Use gait belt for all hands on transfers from one surface to another. Explain all procedures prior to starting. Advise Resident what is expected to him/her during the transfer. Reassure Resident of safety as needed. Review of an incident report dated 7/10/22, indicated Resident #17 sustained a fall in his/her room while walking. The report indicated a CNA was assisting the Resident to the bathroom but had left him/her to walk alone while she obtained toileting supplies. The incident report failed to indicate Resident #17 was wearing a gait belt when he/she fell. During an interview on 7/20/22 at 2:08 P.M., Certified Nursing Assistant (CNA) #1 said the nurses give a verbal report at the start of shift and the CNAs are told the needs of all residents. CNA #1 said if a resident requires a gait belt or assistance with mobility, this would be told during the verbal report. CNA #1 said staff should use gait belts on all residents who require assistance with ambulation. CNA #1 said Resident #17 has fallen and would definitely require assistance and a gait belt if ambulating. During an interview on 7/20/22 at 2:12 P.M., Nurse #1 said Resident #17 requires assistance from staff and the use of a gait belt when ambulating. During an interview on 07/21/22 at 8:04 A.M., the Director of Nursing (DON) said the nursing staff verbally communicates residents' needs to the CNAs at the start of shift. The DON said Resident #17 is care planned to have assistance and a gait belt when ambulating and had been left alone at the time of his/her fall.

Based on observation and interview the facility failed to ensure medications were stored in a secure manner and not accessible to unauthorized persons on 1 of 1 resident units. Findings include: Review of the facility policy, entitled, Self-Administration of Medications, dated 2/2021, included the following: * Self -administered medications are stored in a safe and secure place, which is not accessible by other residents. On 7/20/22 at 7:21 A.M., the surveyor observed a levoalbuterol (medication used for shortness of breath) inhaler resting on a resident's overbed table, located next to his/her bed. On 7/20/22 at 1:15 P.M., the surveyor observed a levoalbuterol inhaler resting on top of a resident's bed. The door was open with resident walking up and down the corridor. On 7/21/22 at 7:15 A.M., the surveyor observed a levoalbuterol inhaler resting on the overbed table, next to a resident's bed. During an interview on 7/21/22 at 11:00 A.M., the Director of Nursing said that there are cognitively impaired residents that wander on the unit where Resident #83 resides and all medications must be secured.