**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and resident and staff interview, the facility failed to assess a resident whether the self-administration of medications was clinically appropriate for 1 of 1 sampled resident who was observed to have medication at bedside (Resident #36). Findings included: 1. Resident # 36 was admitted to the facility on [DATE] with multiple diagnoses including emphysema. Resident #36 had a doctor's order dated 11/3/21 for Albuterol sulfate 90 micrograms (mcg) - 2 puff 4 times a day for emphysema. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #36's cognition was intact. Resident #36 was observed on 3/2/22 at 8:25 AM to have the Albuterol Sulfate inhaler in his room. When interviewed, he stated that he had been administering the Albuterol to himself and kept it in his room for more than a month now. Nurse #2, assigned to Resident #36 was interviewed on 3/2/22 at 12:08 PM. She stated that she was not sure whether Resident #36 was assessed for self- administration, but she knew that he had been self-administering the Albuterol inhaler and was keeping it in his room for a while now, more than a month. The Nurse Unit Manager was interviewed on 3/2/22 at 12:17 PM. She stated that she was not aware and was not informed that Resident #36 had been self-administering his inhaler. She reported that when she was informed on 3/2/22, she had completed the self-administration of medication assessment for Resident #21 and initiated the care plan. The Director of Nursing (DON) was interviewed on 3/2/22 at 4:10 PM. The DON stated that she expected that self-administration of medications assessment was completed, and care plan initiated before the resident could start self-administering medications. She also verified that she was not aware that Resident #36 was administering the Albuterol inhaler to himself. The DON added that she expected nursing to inform the Unit Managers and the MDS Nurse of resident's desire to self-administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and staff interviews, the facility failed to ensure the alternating pressure reducing air mattress was set according to the resident's weight (Residents #7 and #75). This was for 2 of 6 residents reviewed for pressure ulcers. The findings included: 1) Resident #7 was originally admitted to the facility on [DATE] with diagnoses that included diabetes type 2, morbid obesity, and chronic pain. A review of Resident #7's active physician orders revealed an order dated [DATE] for an alternating air mattress to aide in wound healing and pressure relief and to check the function every shift. A review of Resident #7's weight history included the following: - On [DATE] was 229 pounds (lbs.) - On [DATE] was 232 lbs. - On [DATE] was 231.2 lbs. - On [DATE] was 221.8 lbs. Resident #7's care plan, last reviewed [DATE], included a problem area for the potential for skin breakdown secondary to incontinence, impaired mobility, fragile skin due to diabetes, history of unstageable pressure ulcers to the right and left buttocks, right outer ankle and a diabetic ulcer. The interventions included an air mattress. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 had moderately impaired cognition. She was coded with no pressure ulcers however had a pressure reducing device to the bed. Resident #7's weight on [DATE] was 222.2 lbs. On [DATE] an observation was made of Resident #7 while she was lying in the bed with her eyes closed. The alternating pressure reducing mattress machine was observed set on 350 lbs. The machine had weight settings from 90 to 660 lbs. and indicated to set according to the resident's weight per lbs. Resident #7 was observed lying in her bed on [DATE] at 11:55 AM and the alternating pressure reducing mattress machine was set at 350 lbs. On [DATE] at 9:55 AM, Resident #7 was observed lying in bed with her eyes closed. The alternating pressure reducing mattress machine was set at 350 lbs. The treatment nurse was interviewed on [DATE] at 10:05 AM and stated the nursing staff were responsible for checking the alternating pressure reducing mattresses every shift to ensure they were functioning properly. An interview occurred with Nurse #3 on [DATE] at 10:10 AM and stated nursing staff were to check the alternating pressure mattress to ensure they were inflated and functioning every shift but didn't change or check the settings for the weight. An interview was conducted with the maintenance supervisor on [DATE] at 10:40 AM and stated when an alternating pressure reducing mattress was ordered, he would put the mattress on the bed and ensure all the ports were hooked up correctly. The resident's weight was obtained from the nurse and entered at that time. The maintenance supervisor stated he made daily rounds only to ensure the CPR (cardio pulmonary resuscitation) settings were functioning. On [DATE] at 2:00 PM, an observation of Resident #7's alternating pressure reducing mattress was observed with the Director of Nursing (DON), as well as a review of Resident #7's weight history. The DON verified the weight setting should not have been 350 lbs. The DON added nursing staff checked the functionality of the mattresses every shift but was unsure if they checked the actual weight settings. 2. Resident # 75 was admitted to the facility on [DATE] with multiple diagnoses including Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #75 had 4 stage 3 and 1 unstageable pressure ulcers. The assessment indicated that the resident's weight was 113 pounds (lbs.). Resident #75's care plan dated [DATE] was reviewed. The care plan problem was Resident #75 currently has stage 3 pressure ulcers to his right ankle, right heel, left and right ischium and coccyx. The goals were the resident will be free from further skin breakdown and his wounds will show signs of improvement/healing. The approaches included air mattress on bed to aid in pressure relief. Resident #75 was observed in bed on [DATE] at 10:30 AM, [DATE] at 10:35 AM and on [DATE] at 10:05 AM. He had an air mattress in his bed and the machine had a setting selection in lbs. and it was set at 290 lbs. The Treatment Nurse was interviewed on [DATE] at 10:06 AM. She stated that the nurses were responsible for checking the air mattress to ensure it was working and at the correct setting. She reported that the air mattress used by Resident #75 should have been set according to the resident's weight. She observed the air mattress of Resident #75 and verified that the machine was set at 290 lbs. Nurse # 3, assigned to Resident #75, was interviewed on [DATE] at 10:10 AM. She stated that she checked the air mattress daily to ensure the mattress was inflated and functioning properly. She reported that she had not been checking the settings on the machine including the weight setting. The Director of Nursing (DON) was interviewed on [DATE] at 4:10 PM. The DON stated that the Maintenance Director was responsible for the original setting of the air mattress and the nurses were responsible for monitoring the function and the setting daily. The DON verified that the air mattress machine should be set according to the resident's weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review, the facility failed to ensure and monitor that a disposable lighter was secured when not in use or left unattended by a resident identified as a safe smoker. This was for 1 (Resident #36) of 3 residents reviewed for accidents. The findings included: Resident #36 was admitted on [DATE] with a diagnosis of a Cerebral Vascular Accident. Resident #36's quarterly Minimum Data Set, dated [DATE] indicated he was cognitively intact and exhibited no behaviors. Review of a smoking risk assessment dated [DATE] indicated Resident #36 was a safe independent smoker. Resident #36 was care planned dated 7/2/21 and revised 2/15/22 indicated he used tobacco. Interventions included explaining the smoking policy to him and to explaining to him where the designated area were located. An observation on 2/28/22 at 3:05 PM was completed. Resident #36 was not in his room. Observed on his bed visible from the hallway was a opened pack of cigarettes and a disposable lighter. An interview was completed on 3/1/22 at 9:25 AM with Nurse #4. She stated residents identified as a safe smoke were allowed to keep their cigarettes and lighter in their possession. Nurse #4 stated she was uncertain if lighters needed to be secured. She stated there were some residents with dementia known to wander into other residents rooms. An interview was completed on 3/1/22 at 9:28 AM with the Maintenance Director. He stated if the resident was a safe smoker, their lighters did not have to be secured. He said the safe smokers were told to keep the lighters in their possession at all times. An observation on 3/1/22 at 9:40 AM was completed. Resident #36 was not in his room. Observed on his bed side table was one cigarette and a disposable lighter. Resident #36 was observed outside smoking in the designated smoking area. An interview was completed on 3/2/22 at 9:50 AM with Nursing Assistant (NA) #3. She stated Resident #36 was a safe smoker and could go smoke whenever he wanted too. She stated he could keep his smoking materials (cigarettes and lighter) in his possession. NA #3 stated she did not think there was a secure place in the rooms to lock up a lighter when it wasn't in use. She stated Resident #36 knows to keep his disposable lighter in his possession at all times and to never leave it out unattended. An interview was conducted on 3/2/22 at 10:00 AM with NA #2. She stated the nurses complete an assessment to determine if a resident was a safe smoker. NA #2 stated supervised smokers had their smoking materials kept at the nurses station and someone had to go out with them to smoke. If the resident was identified as a safe smoker, they were allowed to keep their smoking materials (cigarettes and lighter) with them. NA #2 further stated the safe smokers had a lock on their nightstand to secure their lighters and were given a key to lock the top drawer. An interview was completed on 3/2/22 at 12:20 PM with Resident #36. He was sitting in his wheelchair eating lunch. There was no observed cigarettes or lighter out in the open. Resident #36 stated he was told he could keep his lighter and never told he had to keep his lighter locked up in his room when not in use or out of his room. Resident #36 stated he kept his disposable lighter in his pocket but on occasion, he would forget and leave it unsecured when he wasn't in the room. Resident #36 stated he did not have a place to secure his lighter even if he wanted too. He stated his nightstand did not have a lock on it and he had not been provided a box to lock his lighter and cigarettes in. Resident #36 stated some of the rooms in the facility had been renovated and the new nightstand in those rooms had a lock on them. He stated he assumed he would have to wait until his room was remodeled that he would have a new nightstand with a lock on it. An interview was completed on 3/2/22 at 4:14 PM with the Administrator. She stated safe smoking residents were told to keep their smoking materials (cigarettes and lighter) on their person at all times. She stated the facility had a quarterly meeting with the smoking residents and there had been no problems with the residents keeping their lighters secured. The Administrator stated she understood there was a risk and possibly the safe smoking residents should have a lock box or a new nightstand with a lock to secure smoking items. She stated the plan was to replace the nightstands during the room remodel but there had been delays in the remodeling. She stated if a resident wanted a lock box, the facility would provide it. An interview was completed on 3/3/22 at 9:29 AM with the Social Worker (SW). She stated they held smoking meetings quarterly and independent smokers could keep their smoking material (cigarettes and lighter) on their person or in a drawer. She stated the items should not be left out visible unattended. If it was discovered that a resident was not compliant with securing a lighter, the facility would meet with that person and discuss the smoking privileges. The SW stated Resident #36 had not been identified as being noncompliant with securing his lighter. She stated to her knowledge, no one person at the facility was actually completing observations rounds to ensure there was no unsecured lighters left out visible. She stated if the floor staff observed Resident #36 leaving his lighter out, they should report it for management to follow up. Resident #36 was observed sitting in his doorway on 3/3/22 at 10:20 AM. Observed on his bed was a gray colored lock box. He stated he didn't know why the lock box was in his room and stated it wasn't there earlier this morning. Resident #36 further stated he was remind to keep his lighter in his pocket yesterday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to provide a physician's ordered diet for 1 of 6 residents (Resident #40) reviewed for nutrition. The findings included: Resident # 40 was admitted to the facility on [DATE] with diagnoses that included laryngeal cancer, dysphagia, malnutrition, and frontotemporal dementia. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired, required assistance with meal set up, and received a therapeutic, mechanical soft diet during the assessment period. Resident #40's comprehensive care plan was last updated 2/21/2022 and had a focus for difficulty eating related to side effects from radiation therapy for laryngeal cancer. He required mechanically altered diet, puree with nectar thick liquids. A review of Resident #40's medical record revealed he had a physician's order for regular pureed diet with nectar thick liquids. The order had a start date of 11/3/2021 with no end date. Resident #40's medical record also reveal he was assessed by the Registered Dietician (RD) on 3/1/2022. The RD's assessment read in part, the resident's diet remains regular with puree texture and nectar thickened liquids, ice cream on lunch and dinner tray, and is supplemented with house supplement twice daily. On 3/1/2022 at 1:00 PM Nurse Assistant (NA) #1 was observed delivering a meal tray to Resident #40 that consisted of a hot dog in a bun with mustard and ketchup and a side item of steak fries. The NA provided tray set up and exited the room. The NA then walked out of the room and down the hall to assist meal tray delivery on another hall. At 1:03 PM on 3/1/2022 an interview was conducted with Nurse #1 who was seated at the nurse's station. When asked what diet was ordered for Resident #40, she stated he was on a pureed diet. When made aware the resident had a hot dog and fries on his meal tray, she notified NA #1 the resident was on a pureed diet. At 1:05 PM observed Nurse #1 and NA #1 remove meal tray from Resident #40. When asked if the resident had a meal tray ticket, NA #1 stated he did. When asked what the meal tray ticket indicated for diet. The NA and Nurse #1 both stated the meal ticked reflected the resident should have received regular puree diet. NA#1 stated it was an oversight, she only saw the word regular. On 3/01/2022 at 2:02 PM and interview was conducted with the Dietary Manager (DM). She stated she was training a new employee on the tray line. She stated the employee only read the first word, regular, and did not read the complete order which read, regular pureed. The DM stated she stepped away from the new employee briefly to plate a renal diet and she must have missed the error. An interview was conducted with the Director of Nursing (DON) on 03/03/2022 at 11:08 AM. She stated she was aware of the incident, and it was her expectation the resident's receive therapeutic diets prescribed by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to administer oxygen at the prescribed rate for 1 of 3 residents reviewed for respiratory care (Resident #7). The findings included: Resident #7 was originally admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). A review of the active physician orders included an order dated 10/19/21 for oxygen at 3 liters via nasal cannula continuously. Resident #7's active care plan revealed a problem area, last reviewed 12/28/21, for oxygen therapy secondary to COPD, chronic respiratory therapy and obstructive sleep apnea. The interventions included to administer oxygen per physician orders. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #7 had moderately impaired cognition and received oxygen therapy. On 2/28/22 at 12:00 PM, an observation was made of Resident #7 while she was lying in bed. The oxygen regulator on the concentrator was set at 2 liters flow by nasal cannula when viewed horizontally at eye level. On 3/1/22 at 11:55 AM, an observation was made of Resident #7 which revealed the oxygen regulator on the concentrator was set at 2.5 liters flow by nasal cannula when viewed horizontally at eye level. An observation was made of Resident #7 while she was lying in bed on 3/2/22 at 9:55 AM. The oxygen regulator on the concentrator was set at 2 liters flow by nasal cannula when viewed horizontally at eye level. On 3/2/22 at 2:00 PM, an observation was made of Resident #7 with the Director of Nursing (DON). The DON verified the oxygen regulator on the concentrator was set at 2 liters when viewed horizontally at eye level and adjusted the flow to administer 3 liters of oxygen as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors of 26 opportunities resulting in a medication error rate of 7.69% for 1 of 5 residents observed during the medication pass (Resident #36). Findings included: The facility's policy in administering medications through a metered dose inhaler dated October 2010 read in part Allow at least one minute between inhalations of the same medication and, at least 2 minutes between inhalations of different medications. The manufacturer's instruction for Albuterol Sulfate inhalation indicated if your doctor has told you to use more sprays, wait at least one minute and shake the inhaler again. 1 a. Resident #36 was admitted to the facility on [DATE] with multiple diagnoses including emphysema. Resident #36 had a doctor's order dated 11/3/21 for Albuterol Sulfate 90 micrograms (mcg) - 2 puffs 4 times a day for emphysema. Resident #36 was observed on 3/2/22 at 8:25 AM during the medication pass. Resident #36 was observed to self- administer 2 puffs of the Albuterol with 5 seconds in between puffs, in front of Nurse #2. Nurse #2 was not observed to give instruction to Resident #36 on how to administer the Albuterol. Nurse #2 was interviewed on 3/2/22 at 9:15 AM. She stated that the facility's policy in administering medications through a metered dose inhaler was to wait 10 minutes or 15 minutes between puffs, but she was not sure. The Director of Nursing (DON) was interviewed on 3/3/22 at 11:10 AM. The DON stated that she expected the nurses to follow the facility's policy in administering medications through a metered dose inhaler. She stated that the facility's policy was to wait at least a minute between puffs of same medication and 2 minutes between puffs of different medications. 1 b. Resident #36 was admitted to the facility on [DATE] with multiple diagnoses including emphysema. Resident #36 had a doctor's order dated 11/3/21 for Anoro Ellipta - 1 puff daily for emphysema. Resident #36 was observed on 3/2/22 at 8:25 AM during the medication pass. Resident #36 was observed to self- administer 2 puffs of the Albuterol in front of Nurse #2. After 10 seconds, Nurse #2 was observed to administer 1 puff of Anoro Ellipta to the resident. Nurse #2 was interviewed on 3/2/22 at 9:15 AM. She stated that the facility's policy in administering medications through a metered dose inhaler was to wait 10 minutes or 15 minutes between puffs, but she was not sure. The Director of Nursing (DON) was interviewed on 3/3/22 at 11:10 AM. The DON stated that she expected the nurses to follow the facility's policy in administering medications through a metered dose inhaler. She stated that the facility's policy was to wait at least a minute between puffs of same medication and 2 minutes between puffs of different medications.