**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to obtain a physician order for medication at the bedside, assess and document self-medication administration for Resident #45. This affected one resident (#45) out of seven residents reviewed for medication administration. The facility census was 97. Findings Include: Review of the medical record for Resident #45 revealed an admission date of 11/18/22. Diagnoses included psoriasis, other pruritus, intrinsic allergic eczema, and chronic kidney disease stage 3. Review of the physician order dated 11/14/23 indicated Triamcinolone Acetonide External Cream 0.5 % (Triamcinolone Acetonide (Topical)), apply to arms, chest, trunk, legs topically every shift on Monday, Tuesday, Wednesday and Thursday for eczema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed no cognitive impairment, and application of ointments/medications were applied other than to the feet during the assessment period. There was no medication self-administration skills assessment. Review of the Treatment Administration Records (TARs) from December 2023 through February 2024 indicated Triamcinolone was signed as administered by the nurses twice daily with no indication Resident #45 was self-administering the medication. Observation on 02/20/24 at 1:44 P.M. revealed one jar of Triamcinolone cream (used to treat eczema) on Resident #45's bedside tray table. Interview at the time of the observation with Resident #45 indicated he applied it for itchy skin when needed. Observation on 02/21/24 at 11:03 A.M. revealed one jar of Triamcinolone cream on Resident #45's bedside tray table. The prescription directions stated to apply to affected areas Monday through Thursday and to take a break on the weekends. Interview at the time of the observation with Resident #45 reported the prescription was from a non-facility pharmacy which he ordered independently and applied it when his skin itched but followed the prescription instructions. Resident #45 stated the dermatologist educated him on how and when to apply the medication but denied facility staff provided any instruction or oversight. Interview on 02/21/24 at 11:05 A.M. with Registered Nurse (RN) #380 verified Resident #45 had a current order for Triamcinolone cream and indicated it was kept at the bedside because Resident #45 applied it himself. RN #380 explained the medication was kept at the bedside and Resident #45 was asked whether the cream was applied, and if so, was documented as given. Sometimes Resident #45 would allow the nurses to apply it. RN #380 indicated only seeing it applied a few times, but reported it was applied correctly when observed. RN #380 confirmed there was no physician order for the medication to be kept at bedside or for self-administration of the medication, and no documentation of the medication being self-administered by Resident #45. RN #380 stated an order should have been obtained and denied assessing Resident #45 for self-administration. RN #380 also stated being unaware of whether the physician knew of the medication at the beside or being self-administered. Interview on 02/21/24 at 11:11 A.M. with Assistant Director of Nursing (ADON) #386 denied knowledge of the Triamcinolone medication at Resident #45's bedside for self-administration. ADON #386 indicated for self-administration or medication at the bedside, a physician order was obtained, and a self-administration skills assessment was completed. ADON #386 confirmed Resident #45 had no self-administration skills assessment completed, and no physician order to keep the medication at the bedside for self-administration. Additional medical record review of Resident #45 revealed a new physician order was initiated on 02/21/24 at 11:43 A.M. for Triamcinolone Acetonide External Cream 0.5 % (Triamcinolone Acetonide (Topical)), apply to arms, chest, trunk, legs topically every shift on Monday, Tuesday, Wednesday, and Thursday. May keep at bedside and self-administer. A progress note dated 02/21/24 at 11:43 A.M. revealed the physician was notified of Resident #45's wishes to self-administer topical Triamcinolone cream and store the medication in the room at bedside. A self-medication administration assessment was completed which determined Resident #45 was able to apply the medication, state its proper use and instructions. The physician agreed to allow Resident #45 to self-administer and maintain the medication at bedside. A self-administration skills assessment was initiated for Resident #45 on 02/21/24 at 11:35 A.M. Review of the facility policy, Self-Administration of Medications, dated 10/30/17, revealed a resident may be offered opportunity to self-administer medications once the physician and the interdisciplinary team concurs the practice is safe and/or is part of discharge planning; self-administration of medications is documented by the licensed nurse on the Medication Administration Record (MAR); and residents who self-administer medications are re-assessed as needed and pursuant to a significant change in condition of the resident to assure that safe self-administration of medications is still feasible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to monitor medication parameters per the physician orders for Resident #40. This affected one resident (#40) of five residents reviewed for unnecessary medications. The facility census was 97. Findings include: Review of the medical record for Resident #40 revealed an admission date of 08/30/23. Diagnoses included Parkinson's disease, hypertension, morbid obesity, unspecified psychosis, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 had severe cognitive impairment. Resident #40 was noted to require moderate assistance for upper body dressing, personal hygiene, mobility, maximum assistance for bathing, and was dependent on staff for toileting and lower body dressing. Review of the physician orders for Resident #40 revealed an order dated 12/13/23 for Metoprolol Tartrate oral tablet 25 milligrams (mg). Give 12.5 mg by mouth two times a day related to essential (primary) hypertension. Hold for heart rate less than 60 or systolic blood pressure (SBP) less than 110. Review of the Medication Administration Record (MAR) for February 2024 for Resident #40 revealed heart rate and blood pressure monitoring were not completed twice daily per the physician's orders when Metoprolol Tartrate was administered. Interview on 02/22/24 at 12:00 P.M. with the Director of Nursing (DON) confirmed the parameters for Metoprolol Tartrate were not being monitored per physician order for Resident #40. Review of the facility policy titled Medication Administration, dated 06/21/2017, revealed under procedure number one revealed to check medication administration record for order. Read label three times before administering, comparing with the MAR.