**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, observation, and interview, the facility failed to ensure medications were administered according to professional standards as well as the facility policy for 1 resident (#75) of 4 residents reviewed for medication administration. The findings include: Review of the facility policy .Self Administration of Medication . reviewed date 4/15/19 revealed .If the resident desires to self-administer medication, an order for self-administration will be obtained from the physician, and an assessment is conducted .the resident's cognitive, physical, and visual ability to carry out this responsibility . Medical record review revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including Hydronephrosis with Renal and Uretheral Obstruction, Need for Assistance with Personal Care, and Major Depressive Disorder. Medical record review of the current physician's recapitulation orders dated 11/1/19 revealed .Ipratropium- Albuterol Solution (type of orally inhaled breathing treatment) .inhale orally via nebulizer (type of delivery device) .every 12 hours . Continued review of the physician's recapitulation orders revealed no documentation of an order to self-administer the medication. Medical record review of an admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5 on the BIMS indicating severe cognitive impairment. Observation of Registered Nurse (RN) #1 on 11/13/19 at 7:41 AM, on the east wing hallway, revealed the RN entered Resident #75's room and started the breathing treatment for the resident and left the room. Continued observation revealed the RN then proceeded to administer other resident's medications not in view of the resident. Interview with RN #1 on 11/13/19 at 8:03 AM, on the east wing hallway, revealed the resident did not have an order for self-administration and had not been assessed for self-administration of medications. Interview with the Director of Nursing (DON) and the MDS Coordinator on 11/13/19 at 8:40 A.M., in the facility conference room, confirmed the resident had not been assessed for self-administration of medications and the resident would not be unable to self-administer medications due to her cognitive status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to revise a care plan for wandering behavior for 1 resident (#96) of 32 residents reviewed. The findings include: Review of the facility policy, Assessments & Care Plans revised 4/29/19, revealed .The Care Plan includes measure objectives, timeframes to meet the patient's, cultural, nursing, mental, and psychosocial needs including services being provided to meet those needs . Medical record review revealed Resident #96 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Anxiety Disorder, Osteoarthritis and Falls. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #96 is rarely/never understood, required supervision for locomotion and exhibited wandering behaviors daily. Medical record review of the comprehensive care plan dated 11/8/19 revealed .has a potential behavior problem r/t [related to] advanced dementia, wandering in w/c, hollering out at staff, very repetitive kicking back of others w/c to tell them to move. Disruptive to others at times. Turns off office lights, may wander into others rooms hollering .Hurry, Hurry, go on go on. Staff to continue to monitor and attempt to redirect to best of staff ability .revised 3/25/19 . Observation of Resident #96 on 11/12/19 at 12:26 PM, seated in a w/c self- propelling into the dining room, yelling loudly Open the door. Observation of Resident #96 on 11/12/19 at 12:30 PM, seated in a w/c, redirected by staff out of the dining room. Observation of Resident #96 on 11/13/19 at 2:40 PM sitting in a w/c in the hallway yelling at staff. Continued observation revealed a staff member offered the resident gum. Interview with Certified Nursing Assistant #1 on 11/13/19 at 2:05 PM, at the 100 nursing station, confirmed Resident #96 wanders in other resident's room frequently and is very difficult to redirect. Interview with Licensed Practical Nurse #1 on 11/13/19 at 2:15 PM, at the 100 nursing station, confirmed Resident #96 wanders. Continued interview confirmed staff redirect the resident .That's all we can do . Interview with the DON on 11/13/19 at 3:20 PM, in the conference room, revealed new interventions to offer chewing gum and take the resident outside had been implemented. Continued interview confirmed the new interventions had not been added to the care plan until 11/13/19.

Based on observation and interview the facility failed to maintain dignity during the dining observation for 14 of 24 residents reviewed for dining services. The findings include: Observation of the main dining room on 11/12/19 from 11:15 AM to 12:35 PM revealed 10 residents sitting at 3 tables received their food trays at 11:22 AM. Continued observation revealed 2 staff members assisted the resident's with their meals. Further observation revealed the 14 additional residents did not receive a tray until 12:27 PM, 1 hour and 5 minutes later. Interview and observation with the Director of Nursing (DON) on 11/12/19 at 12:25 PM, in the main dining room, revealed the 10 residents which received their trays first at 11:22 AM, were residents which received restorative services. Continued interview revealed the residents which received restorative dining services used to be in a separate dining area which is now occupied by therapy. Further interview revealed the DON stated .It is normal for the 14 additional residents to come to the dining room at the same time as residents which received restorative dining. Continued interview confirmed the 14 residents had to wait to be fed 1 hour and 5 minutes after the other 10 residents residents were fed in the dining room by facilty staff.

Based on observation and interview the facility failed to ensure proper space during the dining observation for 14 of 24 residents reviewed for dining services. The findings include: Observation of the main dining room on 11/12/19 from 11:15 AM to 12:35 PM revealed 10 residents sitting at 3 tables received their food trays at 11:22 AM. Continued observation revealed 2 staff members assisted the resident's with their meals. Further observation revealed the 14 additional residents did not receive a tray until 12:27 PM, 1 hour and 5 minutes later. Interview and observation with the Director of Nursing (DON) on 11/12/19 at 12:25 PM, in the main dining room, revealed the 10 residents which received their trays first at 11:22 AM, were residents which received restorative services. Continued interview revealed the residents which received restorative dining services used to be in a separate dinning area which is now occupied by therapy. Further interview revealed the DON stated .It is normal for the 14 additional residents to come to the dining room at the same time as residents which received restorative dining. Interview with the DON confirmed .we just have an older building not enough room for separate dining area .