**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined that the facility failed to ensure that a resident was clinically appropriate to self-administer their medications for 1 of 3 residents reviewed for choices in a final sample size of 23 residents (Resident Identifier #4). Findings include: Observation on 5/20/24 at approximately 9:15 a.m. in Resident #4's room revealed the following medications on a shelf near the resident sitting in his/her recliner: 1 bottle of Biotics Calcium; 1 bottle of Turmeric m1670; 1 bottle of Vitamin C 500 milligrams (mg); 1 bottle of [NAME] Liquid. Interview on 5/20/24 at approximately 9:15 a.m. with Resident #4 revealed that he/she takes the medications on his/her own. Further interview revealed that Resident #4 administers: [NAME] liquid -daily for his/her blood pressure; Turmeric m1670- as needed for pain; Vitamin C -1 or 2 times per week; Biotics Calcium -daily. Observation and interview on 5/21/24 at approximately 8:30 a.m. with Staff E (Licensed Practical Nurse) of Resident #4's room revealed the above medications on a shelf near the resident sitting in his/her recliner. Staff E confirmed the findings. Review on 5/21/24 of Resident #4's May 2024 Medication Administration Record (MAR) revealed the following physician order's: [NAME] Oral Capsule 150 mg ([NAME]) Give 1 capsule by mouth in the morning every 2 day(s) for supplement. Unsupervised self-administration, family provides. Start Date 12/30/23. Further review of Resident #4's MAR revealed that he/she did not have physician's order for Turmeric m1670, Vitamin C 500 mg and Biotics Calcium. Review on 5/21/24 of Resident #4's medical record revealed that there was no assessment for self administering medications done with Resident #4. Interview on 5/21/24 at approximately 12:30 p.m. with Staff F (Director of Nursing) confirmed that Resident #4 was not assessed for the ability to self administer medications. Interview on 5/21/24 at approximately 1:50 p.m. with Staff K (Nurse Practitioner) revealed that he/she was not aware of Resident #4 administering his/her medication. Staff K also revealed that they were not aware of Resident #4 administering the [NAME] liquid every day instead of every other day. Review on 5/21/24 of the facility policy titled, Self-Administration By Resident, Dated 11/17 revealed: .Procedures: 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care plan process .

Based on interview and record review, it was determined that the facility failed to report an allegation of misappropriation to the State Survey Agency (SSA) for 1 out of 9 allegations reviewed (Resident Identifier #42). Findings include: Review on 5/20/24 of the facility grievance log revealed the following allegation of misappropriation that was not reported to the SSA: Resident #42 Review on 6/4/23 a grievance was filed by Resident #42's Durable Power of Attorney (DPOA) for Resident #42's missing gold and diamond wedding ring set. Interview on 5/20/24 at approximately 12:00 p.m. with Staff A (Social Worker) revealed that the missing items were not reported to the SSA or the local police. Interview on 5/21/24 at approximately 8:45 a.m. with Staff D (Administrator) confirmed the above findings. Review on 5/20/24 of the facility policy titled, Abuse Prevention and Reporting, Revision Date 10/24/22 revealed: .3. All alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source and misappropriation of resident property, will be reported immediately after the incident is discovered or observed by the employee to the employee's supervisor on duty. The supervisor on duty has the responsibility to report same immediately to the facility Administrator (or designee). The facility will investigate and report all allegations of abusive conduct to the state agency. 4. Initial Report The administrator or designee will report alleged violations involving abuse, neglect or mistreatment, including injuries of unknown source and misappropriation of resident property, and exploitation to the . the State Agency through the Ombudsman's Office reporting system immediately .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to follow physician orders for 1 resident out of 5 residents reviewed for unnecessary medications and for 1 of 31 medications observed for medication administration in a final sample of 23 residents (Resident Identifier #157 and #65). Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Review on 5/21/24 of Resident #157's May 2024 Medication Administration Record (MAR) revealed the following physician's order: Midrodrine HCL [Hydrochloric Acid] Tablet 10 mg [milligrams], Give 1 tablet by mouth three times a day for BP [Blood Pressure] hold for SBP [Systolic Blood Pressure] greater than 160. Do not give after 6 pm., Start Date 5/7/24. Further review revealed that the medications were held with the following blood pressures: 5/17 SBP 151; 5/18 SBP 143. Interview on 5/21/24 at approximately 1:30 p.m. with Staff F (Director of Nursing) confirmed the above findings. Resident #65 Review on 5/20/24 of Resident #65's medication orders revealed an order for Midodrine 5mg, take by mouth three times per day related to orthostatic hypotension. Hold for SBP > (greater than symbol) than 110. Observation on 5/20/24 at approximately 8:30 a.m. with Staff H (Licensed Practical Nurse) revealed Staff H obtained Resident #65's SBP reading of 149. Staff H then poured Midodrine (medication to prevent blood pressure from dropping) to be administered to Resident #65. Interview on 5/20/24 at approximately 8:35 a.m. with Staff H confirmed that medication should not be administered as Resident #65's SBP was 149, which is greater than 110. Interview further revealed that Staff H did not understand the symbols used to indicate greater than in the physicians' order. Review on 5/20/24 of Resident #65's MAR for May 2024 revealed that 5 doses of Midodrine were given with a SBP greater than 110. The doses were as follows: On 5/2/24 the evening dose was administered with a SBP of 162; On 5/5 24 the evening dose was administered with a SBP of 126; On 5/7/24 the evening dose was administered with a SBP of 154, On 5/16/24 the afternoon dose was administered with a SBP of 148; On 5/16/24 the evening dose was administered with a SBP of 147. Review on 5/20/24 of Resident #65's May 2024 MAR revealed the following physician's order: Lutein Oral Capsule 6 mg, Give 1 capsule by mouth in the morning for supplement, Start Date 11/1/23. Further review revealed that on 5/2, 5/3, 5/4, 5/6, 5/8, 5/9, and 5/10 the medication was indicated as not being available. Interview on 5/21/24 at approximately 1:30 p.m. with Staff F confirmed the above findings. Interview on 5/21/24 at approximately 1:50 p.m. with Staff K (Nurse Practitioner) revealed that he/she was not notified of the medication not being available. Review on 5/21/24 of the facility policy titled, 3.12 Medication Shortages, dated 9/10 revealed: .2. Nursing staff shall, if the shortage will impact the patient's immediate need of the ordered product: a. Notify the attending physician of the situation, explain the circumstances, expected availability and optional therapy(ies) that are available. b. Obtain a new order and cancel/discontinue the order for the non-available medication .

Based on observation and interview, it was determined that the facility failed to ensure that medications were secured for 1 of 4 medication carts observed. Observation on 5/20/24 at 8:20 a.m. of the third floor Westside Medication Cart revealed it was unlocked with no staff within sight. There were 4 residents seated at tables and eating breakfast within 10 feet of the unlocked medication cart. Interview on 5/20/24 at 8:24 a.m. with Staff J (Medication Nursing Assistant (MNA)) confirmed the cart was unlocked while he/she stepped away for a few minutes. Review of facility policy, Medication Storage, dated 01/2021, revealed: .Procedures: .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allow access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access .

Based on interview, observation, and record review, it was determined that the facility failed to ensure that all alleged violations of abuse, neglect, exploitation or mistreatment were thoroughly investigated for 1 of 2 residents reviewed for abuse in a final sample of 18 residents (Resident identifier is #32). Findings include: Resident #32 Observation on 4/25/23 at approximately 12:14 p.m. of Resident #32 revealed a large greenish purple area to their right wrist going from under the wrist, at mid-circumference, extending around to the top of wrist and going up to the top of the pinky finger. The top of the hand appeared to be slightly swollen compared to the left hand and surrounding skin was slightly darker pink in color than the left hand. Interview on 4/25/23 at approximately 12:20 p.m. with Staff D (Licensed Nursing Assistant) confirmed the discolored area on Resident #32's right wrist and hand. Staff D stated he/she had seen the areas last Wednesday [4/19/23] and reported this finding to Staff F (Registered Nurse). Interview on 4/25/23 at approximately 12:30 p.m. with Staff A (Nurse Manager) revealed he/she was unaware of this area to Resident #32's wrist and hand and there was no investigation of the injury of unknown orgin.

Based on interview and record review, it was determined that the facility failed to notify the provider of a change in residents' condition and failed to assess and monitor identified areas of concern for 1 of 2 residents reviewed for abuse out of a final sample of 18 residents (Resident identifier is #32). Findings include: Resident #32 Observation on 4/25/23 at approximately 12:14 p.m. of Resident #32 revealed a large discolored area to their right outer wrist going from under the wrist, at mid-circumference, extending around to the top of wrist and going up to the pinky finger. The area appeared to be slightly swollen compared to left hand and the surrounding skin was slightly darker pink in color than the left hand. Review on 4/26/23 of Resident #32's medical record revealed no documentation regarding Resident #32's bruised right wrist and hand until a note dated 4/25/23, with an entry time of 1:29 p.m., stated that a bruise of unknown origin was noted to right hand. Blueish in color swelling and pain noted. Nurse Practitioner and DPOA [Durable Power of Attorney] notified at that time and [an] x-ray ordered., Further review of Resident #32's medical record revealed the x-ray of the right wrist and hand showed evidence of a right fractured 5th finger. Interview on 4/26/23 at approximately 9:00 a.m. with Staff A (Nurse Manager) confirmed the above areas and stated he/she was not aware of the areas on Resident #32's right hand and wrist. Interview on 4/27/23 at approximately 9:05 a.m. with Staff F (Registered Nurse) revealed he/she had been made aware of the discolored area to the right hand on 4/19/23, but at the time was only discolored on the top of the hand. Staff F stated he/she reported this to Staff A at the daily meeting and initiated a treatment order to monitor the area twice a day. Staff F confirmed he/she did not write a note or call a provider about the area.

Based on observation, interview, and policy review it was determined that the facility failed to ensure expired medications were properly disposed of in 1 of 3 medication rooms and on 1 of 6 medication carts (Resident identifiers are #67 and #87). Findings Include: Second Floor Medication Room Observation on 4/25/23 at 8:45 a.m. of the second floor medication room revealed a bottle of Pantoprazole Sodium 40 milligram (mg) tablets, expired 1/2023, and a bottle of Levothyroxine Sodium 75 microgram (mcg) tablets, expired 10/30/22, available for use for Resident #67. Interview on 4/25/23 at 8:45 a.m. with Staff G (Registered Nurse) and Staff H (Licensed Practical Nurse) confirmed Resident #67 was prescribed the above medications and confirmed the finding. Review of facility's Medication Storage policy revealed: Outdated, contaminated, discontinued or deteriorated medications .are immediately removed from stock, disposed of . Fourth Floor Medication Cart Observation on 4/25/23 at 9:15 a.m. of the fourth floor medication cart revealed a vile of Insulin Aspart 100 units/milliliter (ml) in use with an open date of 3/18/23 (open expiration date of 4/15/23) for Resident #87. Interview on 4/25/23 at 9:15 a.m. with Staff I (Registered Nurse) and Staff J (Assistant Director of Nursing) confirmed the finding. Review of Insulin Aspart manufacturer specifications revealed: Throw away all opened insulin aspart vials after 28 days, even if they still have insulin left in them.