Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for self administration of medications for 1 of 1 sampled resident (#1) reviewed for medication administration. This placed residents at risk for adverse medication related consequences. Findings include: The facility's 8/2024 Self-Medication policy outlined the following criteria for a resident to self-administer medications: -The resident must successfully pass the Medication Self-administration Safety Screen; -Their primary care physician must approve their request to self-administer medications; and -They must consistently secure their medications out of the reach of others. Resident 1 was admitted to the facility in 2/2025 with diagnoses including left leg fracture and amnesia. A review of Resident 1's 2/18/25 admission MDS revealed she/he had moderately impaired vision and required cueing for recall. On 3/11/25 at 10:36 AM, Resident 1 was observed to have the following medications on her/his bedside table: -Two tubes of Benadryl itch stopping cream. -One tube of Benadryl extra strength itch stopping gel. -One tube of GC dry mouth gel. -Three tubes of Systane night time eye lubricant gel. -Two bottles of TheraTears lubricant eye drops. On 3/11/25 at 10:36 AM, Resident 1 stated the medications on the bedside table were her/his and she/he applied the Benadryl and TheraTears herself/himself several times each day. Resident 1 also stated she/he did not remember the last time she/he used the Systane. On 3/11/25 at 11:16 AM, Staff 4 (RN) stated residents were allowed to self administer medications with a physician's order and successful completion of an evaluation. Staff 4 stated the resident needed to name the medication, its use, and when it was given. Staff 4 acknowledged Resident 1 did not complete the evaluation and did not have an order from her/his physician for medication self administration. On 3/11/25 at 11:30 AM, Staff 3 (DNS) stated she expected residents to have a physician order and complete an assessment to self administer medications.

Based on observation, interview and record review it was determined the facility failed to ensure biologicals were stored securely and not accessible to unauthorized individuals for 1 of 1 sampled medication room reviewed for medication storage. This placed residents at risk for unauthorized access to drugs and biologicals. Findings include: The facility's 8/2024 Medication Management Policy & Procedure specified refrigerated medications were kept in a locked, secure refrigerator and all medications were stored in rooms accessible to authorized personnel. On 3/11/25 from 9:05 AM through 10:02 AM the unit's skilled nursing office door was propped open. During this time, various staff members went in and out of the room, and non-staff construction workers walked by the room. A white refrigerator and a silver refrigerator were observed inside the office. On 3/11/25 at 10:02 AM, Staff 4 (RN) reviewed the contents of the refrigerators. The silver refrigerator was empty and the white refrigerator contained an Aplisol vial (used for tuberculosis testing). Staff 4 stated the white refrigerator was used to store drugs and biologicals. On 3/11/25 at 10:18 AM, Staff 4 stated the refrigerator was not routinely locked. Staff 4 confirmed the office door was open and unlocked since 9:00 AM and the contents of the unlocked refrigerator were accessible to unauthorized staff and personnel. Staff 4 stated the office door should be locked at all times since the refrigerator remained unlocked. On 3/11/25 at 3:53 PM, the office door was observed open and no staff were in the office. On 3/12/25 at 8:22 AM, the office door was observed open and no staff were in the office. On 3/12/25 at 9:29 AM, Staff 3 (DNS) stated the office refrigerator was used to store drugs and biologicals. Staff 3 was notified the office door was unlocked and accessible to unauthorized personnel on 3/11/25 and 3/12/25 and the refrigerator was left unlocked. At 9:37 AM, Staff 3 observed the unlocked refrigerator and stated the door to the office and the refrigerator were to be locked at all times.

Based on interview and record review it was determined the facility failed to have a system in place to monitor and document food temperatures for 1 of 1 kitchen reviewed for safe food preparation. This placed residents at risk for food borne illness. Findings include: Review of the facility census indicated two residents resided in the facility. Resident 1 and Resident 2 indicated no concerns regarding food. Review of the residents' medical records revealed no indication of food related illnesses. On 1/3/24 at 10:42 AM during a kitchen observation, Staff 4 (Dining Manager) and Staff 5 (Executive Sous Chef) were asked to provide documentation of the food temperature logs. Staff 4 stated once food was prepared in the kitchen it was placed into the hot box (temperature controlled food cart). Food temperatures were taken and documented by the staff in the skilled unit when the food was removed from the hot box. Staff 4 and Staff 5 stated food temperatures were not taken in the kitchen and there was no documentation of food temperatures. On 1/3/24 at 11:20 AM Staff 3 (RN) stated there was no documentation kept of food temperatures in the skilled unit. On 1/3/24 11:20 AM Staff 2 (DNS) stated nursing staff took food temperatures only when food was reheated. On 1/3/24 at 1:10 PM Staff 1 (Administrator) acknowledged the facility did not have a system in place for monitoring food temperatures and did not have documentation of food temperatures.