**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to discuss discharge instructions with resident and resident representative upon discharge for 1 of 3 resident (R1). Additionally, the facility failed ensure correct disposition of medications for 2 of 3 residents (R1) when R1 received R2's medications upon discharge. Findings include: R1's face sheet, undated, indicated admission date to the facility of [DATE]. R1's diagnoses included atrioventricular block and unspecified diastolic (congestive) heart failure. R1's Minimum Data Set (MDS) dated [DATE], identified intact cognition and no verbal behaviors during the assessment period. R2's face sheet, undated, indicated admission date to the facility of [DATE]. R1's February 2025 Medication Administration Record (MAR) did not indicate administration for sulfamethoxazole or lisinopril. R2's February 2025 MAR indicated administration for sulfamethoxazole 800 milligrams one tablet oral two times daily and lisinopril 20 milligrams one tablet by mouth two times daily. Facility form titled Discharge Sending Medications Homes dated [DATE], indicated sulfamethoxazole 800 milligrams one tablet oral two times daily was listed on R1's form. Lisinopril pharmacy sticker was not visible on form. Discharge Sending Medication Home indicated, I certify the medication listed (pharmacy card stickers) above are released to me, with R1's signature and dated [DATE]. The form failed to have evidence of a witness/nurse signature. During interview on [DATE] at 1:21 p.m., assistant director of nursing (ADON) stated their discharge process included a review of medications with the resident and to answer any questions. ADON was not aware of any medications sent home with the wrong resident and if this were to occur, management should have been notified. During interview on [DATE] at 2:42 p.m., registered nurse (RN)-A stated he worked on the transition care unit at the facility and completed discharge process with the residents. RN-A stated he did not recall completing R1's discharge. RN-A denied sending R2's medication, sulfamethoxazole home with R1, discovering the error later, and then ordering more sulfamethoxazole for R2 later. RN-A stated if an error like that occurred, he would contact his supervisor. During interview on [DATE] at 3:49 p.m., pharmacist (Pharm) stated on [DATE] there was a request by the facility to fill R2's sulfamethoxazole and the facility would be responsible to pay for the additional medications. Pharm stated the facility reported to have used their emergency kit supply of sulfamethoxazole until requesting more on [DATE]. Lisinopril was not reordered but no doses were verified to be omitted for R2. During interview on [DATE] at 4:02 p.m., director of nursing (DON) stated they were not aware of the medication errors until this survey. DON indicated he believed RN-A knew of the error as was the one who ordered more medications for R2, and had not received authorization before ordering. DON stated upon discharge the nurse was to review the discharge paperwork, including the medications that were being sent home with the resident (and/or resident representative). He indicated this was likely not done as the medication disposition error would have been caught at that time if the process was followed. DON added, during their investigation, when reviewing R1's discharge records, the medication sticker for R2's sulfamethoxazole was included in R1's record, solidifying the error. Review of R1's discharge paperwork lacked evidence RN-A discussed discharge paperwork and medications with R1 and family. Additionally, no RN signature was found on the Recapitulation of Stay records. During interview on [DATE] at 2:47 p.m., R1's family member (FM) stated no discharge paperwork or medications were reviewed at the time of discharge. Upon R1 returning home it was discovered another resident's medications (sulfamethoxazole and lisinopril) were sent home with her. FM recalled R1's medications were handed over from RN-A to the family in a bag. FM indicated a serious concern related to this error as, if his mother would have taken these medications, it could have caused her significant harm. Facility policy titled Adverse Consequences and Medication Errors, revised date 2/2023, indicated a procedure was to review the resident's medication regimen for efficacy and actual or potential medication -related problems on an ongoing basis. Monitor the resident for medication-related adverse consequences when there is a medication error (wrong or expired medication). In the event of a significant medication-related error or adverse consequence, take action, as necessary, to protect the resident's safety and welfare. Promptly notify the provider of any significant error. Facility polity titled Transfer or Discharge, Resident-Initiated, dated 10/2022, indicated medical record would contain documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility, discharge care plan and document discussions with the resident or representative, containing details of discharge planning and arrangements for post-discharge care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain confidential clinical records for 2 of 3 residents (R1 and R2) when two of R2's Pharmacy Cards were sent with R1 who was discharging home. Findings include: R1's Minimum Data Set (MDS) dated [DATE], identified intact cognition. R1's February 2025 Medication Administration Record (MAR) did not indicate an order for sulfamethoxazole or lisinopril. R2's MDS dated [DATE], identified intact cognition. R2's February 2025 MAR indicated an order for sulfamethoxazole 800 milligrams one tablet oral two times daily and lisinopril 20 milligrams one tablet by moth two times daily. R2's pharmacy card identified protected information such as his first name, middle initial, last name, his doctor's name and information, the medication and prescribed route/dosage and what the medications were prescribed for (high blood pressure, antibiotic for infection). R2 is protected by the Health Insurance Portability and Accountability Act (HIPPA) which includes protected health information includes medical history, test information, and any personally identifiable information. The 18 HIPPA identifiers include patient names, geographical elements, dates related to health or identity, telephone numbers, social security numbers and more. During interview on 5/7/25 at 1:21 p.m., assistant director of nursing (ADON) stated upon discharge the nurse was to review medications with the discharging resident and or representative; ADON was not aware wrong medications was discharged with the wrong resident. During interview on 5/7/25 at 2:42 p.m., registered nurse (RN) denied sending R1 home with R2's medication. During interview on 5/7/25 at 4:02 p.m., director of nursing (DON) stated they were not aware a resident was discharged with another resident's medications but was able to verify R2's medication sulfamethoxazole pharmacy card sticker was in R1's discharge record. During interview on 5/9/25 at 2:47 p.m., R1's family member verified and provided pictures of R2's medication sulfamethoxazole and lisinopril which was sent home with R1 upon discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure physician-ordered medication was acquired and provided in a timely manner to reduce the risk of pain and complication for 1 of 1 resident (R1) reviewed whose pain medication was sent from the pharmacy however, was never provided as ordered. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 was cognitively intact had medically complex diagnosis, surgical wound with surgical wound care, ulcerative colitis (an inflammatory bowel disease that causes chronic inflammation and ulcers in the superficial lining of the large intestine). Identified R1 required assistance with activities of daily living (ADL's) had mild pain, which was occasional and occasionally affected sleep. R1's Care Plan dated 2/04/25, indicated R1 had chronic pain syndrome, alteration in comfort and pain related to PMR (Polymyalgia rheumatic, inflammatory condition. It causes joint and muscle pain and stiffness, mainly in the shoulders and hips) chronic pain, abdominal pain secondary to sigmoid colectomy. R1's care plan directed staff to assess location, quality, and intensity of pain as indicated, receive opioid medication as ordered, assess for non-pharmalogical interventions, occupational therapy to provide and assist, Methocarbamol for pain/muscle spasms. R1's admission Orders dated 2/04/25, indicated R1 was to receive gabepentin 4%/lidocaine 2% gel topical gel (used for pain) apply two times a day. R1's Medication Administration Record dated February 2025, indicated R1 had not received the scheduled gabapentin 4 % - lidocaine 2% gel twice daily from 2/04/25 through 2/13/25 (over nine days). During an interview on 2/26/25 at 10:20 a.m., R1 stated she admitted to the facility on [DATE], and was to receive her pain gel with lidocaine and gabapentin for several days after admission. R1 stated she used the gel on her right hip and shoulder for pain relief and it helped her sleep. During an observation and interview on 2/26/25 at 1:20 p.m., registered nurse (RN)-B stated the gabepentin/lidocaine gel was not available at the facility for R1. RN-B stated she knew the DON called the pharmacy about it and they documented it was unavailable on the medication administration record (MAR). During an interview on 2/26/25 at 4:30 p.m., the director of nursing (DON) stated he was aware of the gel cream and was informed by their pharmacy at first it was delivered on 2/04/25, and he searched all of the medication carts and was unable to find the gel. The DON then stated he called the pharmacy and was told they were unable to make the compound with the lidocaine and gabapentin. The DON stated he had frustrations with the pharmacy and was planning to have a meeting with them to discuss his concerns. The DON stated the process was for the staff to call the pharmacy if they had not received a medication and the facility had a back-up pharmacy to call as needed. DON stated the system did not work as planned. During an interview on 2/27/25 at 10:10 a.m., R1's nurse practitioner stated she was never informed R1 had not received her gel pain cream for over nine days and had she been informed, she would have checked to see if it was an insurance issue or ordered some other pain cream for her hips and shoulders during that timeframe. During an interview on 2/27/25 at 10:51 a.m., pharmacy director (PD) stated the gel was shipped to the facility on 2/04/25, the tracking form indicated it was filled on 2/04/25, at 5:20 p.m. and loaded in the bin and the only re-fill seen on their end was noted to be on 2/25/25, which would be delivered today. The PD stated they received the original order from the hospital R1 discharged from and their compound book indicated it was made at their pharmacy on 2/04/25. PD stated they had an electronic manifest with a staff nurse signature who signed for the medication on 2/04/25, at the facility. A policy was requested prior to exit of survey however,was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure the multidisciplinary team was involved for 2 of 3 residents (R111and R257) reviewed for self administration of medications(SAM). Finding include: R111's face sheet undated, indicated R111's diagnoses included chronic obstructive pulmonary diease (COPD) and a personal history of pulmonary embolism. R111's admission Minimum Data Set (MDS) dated [DATE], indicated R111 was moderately cognitively impaired, independent with eating after set-up, and required extensive assistance with the rest of his activities of daily living. During initial observation and interview on 8/28/23 at 1:20 p.m., two inhalers were noted at bedside. One on the over the bed table (OBT) to his right and one the bed side chest of drawers to resident's left. The inhaler on the OBT was budesonide-formoterol (a bronchodilator) HFA 160 mcg-4.5 mcg, which had a faded prescription label with R111's name and directions. On the chest of drawers was an inhaler of Albuterol (PROAIR HFA - a bronchodilator) which lacked a label. R111 stated he had COPD and used them when he needed. An observation on 8/29/23 at 9:18 a.m., both inhalers were remained in the same locations as the day before. During an observation on 8/30/23 at 8:40 a.m., the inhalers were no longer in the locations previously observed. However, the chest of drawer's top drawer was open and both inhalers were noted inside. R111's Physician Order Report (print date of 8/30/23) indicated budesonide-formoterol HFA (hydrofluoroalkane - the propellant of the inhaler) 160 micrograms (mcg)-4.5 mcg/actuation aerosol inhaler(2 puffs) HFA AEROSOL WITH ADAPTER every day. R40's physician orders lacked evidence of R40's approval to self-administer medications. However, the report lacked orders for the Albuterol inhaler. R111's electronic medical record included a Assessment for Self-Administration of Medications assessment form (dated 8/14/23). However, the assessment form was blank and unsigned. On 8/30/23 at 9:24 a.m., unit manager (RN)-C verified two inhalers in R111's room. Further, RN-C stated R111 only had an order for the budesonide-formoterol HFA 160 mcg-4.5 mcg inhaler. R111 had cognitive issues, and he would not have been a candidate for self-administration. She was uncertain why a blank self-administration assessment had been entered into R111's medical record. RN-C thought a family member may have brought R111's inhalers into him. RC-C stated facility staff should have returned and reported to the nurse any medication left in a residents room. R257's face sheet, undated, indicated R257's diagnoses included acute respiratory failure, unspecified whether with hypoxia or hypercapnia. R257's admission MDS, still in progress, indicated R257 was cognitively intact and independent with eating. However required extensive assistance with the rest of her activities of daily living. During observation and interview on 8/28/23 at 2:31 p.m., R257 had an inhaler, with a spacer attached, on nightstand at bedside. The inhaler on the nightstand was albuterol (a bronchodilator), which lacked a label. R257 stated she used the inhaler when she needed it. An observation on 8/29/23 at 9:07 a.m., inhaler was in the same locations as the day before. R257's Physician Order Report (print date of 8/30/23) indicated albuterol sulfate HFA 90 micrograms (mcg)/actuation aerosol inhaler (2 puffs) HFA AEROSOL WITH ADAPTER every four hours as needed. R257's physician orders lacked evidence of approval to self-administer medications. R257's electronic medical record lacked an assessment for Self-Administration of Medications. On 8/30/23 at 8:29 a.m., RN-A verified the inhaler in R257's room. RN-A was unaware if R257 had a self-administration order and/or assessment. She went to unit manager RN-B for instruction. RN-B educated RN-A on the process, which consisted of completing the assessment on the computer. When a resident passed the assessment an order would need to be obtained from the provider before the resident could self-administer medications. During interview on 8/30/23 at 8:31 a.m., RN-B stated when a resident verbalized desire to self-administer medication any nurse could do the assessment and obtain an order from the provider. Once the order was received, a note would appear under the medication in the electronic medication record (EMR) indicating the resident could self-administer medication. RN-B confirmed R257 did not have a self-administration assessment completed and there was no order in the EHR from provider. During interview on 8/30/23 at 10:32 a.m., DON stated when a resident had told facility that they would like to self-administer any medications, a self-administer assessment would be completed by nursing and an order would be obtained from the provider. DON stated it was important for the assessment and order for self-administration were completed as the facility needed to make sure the resident was able to safely self-administer medications and understand the risks/benefits of the medications. DON stated it was a huge safety reason. In a review of the facility policy, entitled: Self Administration of Medications (reviewed February 2021), indicated the following: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident ' s cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 2. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self -administration; b. The resident is able to read and understand medication labels; c. The resident can follow directions and tell time to know when to take the medication; d. The resident comprehends the medication ' s purpose, proper dosage, timing, signs of side effects and when to report these to the staff; e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication.