Based observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #29) reviewed for infection control. The facility failed to keep the urine drainage bag off the floor. This failure could place residents at risk of cross-contamination and development of infections. Finding include: During observation on 10/21/2024 at 11:27AM, Resident #29's urine catheter bag was hung on the trash can beside his bed. The bottom of the urine catheter bag was observed to be laying on the floor. During observation on 10/23/2024 at 2:29PM, Resident #29 urine catheter bag was hung on a trash can beside his bed. The bottom of the urine catheter bag was observed to be laying on the floor. During an interview on 10/23/2024 at 2:36PM, CNA-E said, the urine catheter bag was hung wrong and it should not be touching the floor. She said it should not be hung from the trash can, it should be hung from the bed and should be below Resident #29 feet. CNA-E said the urine catheter bag should have been place in a covering bag. During an interview and observation with the DON on 10/23/2024 at 2:40PM, the DON said the urine catheter bag should have been placed in a covering bag. He said he did not know why the urine catheter bag was not in a covering bag. He said the facility just purchased new covering bags. Record review of an undated policy titled, Anchoring - Catheter Bags, indicated: To ensure that all catheter bags are anchored appropriately, they do not touch the ground .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 3 of 4 residents reviewed for pharmacy services (Residents #16, #24, #26). The facility failed to ensure medications were available in the form ordered by the physician for Residents #16 and #24. The facility failed to ensure a physician's order to discontinue an oral diabetic medication and replace it with another medication was carried out resulting in the discontinued medication being given for 3 (three) months after it was discontinued, and the replacement medication not being initiated for Resident #16. The facility failed to ensure LVN D administered insulin to Resident #26 in a safe, therapeutic manner. These failures could place residents at risk for not receiving the intended therapeutic response of prescribed medications and not having accurate records of medication administration which could result in diminished health and well-being. Findings included: 1.A review of Resident #16's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included dementia, cerebral infarction (stroke), and Diabetes Mellitus (a long-tern condition in which the body has trouble controlling blood sugar and using it for energy). During an observation of medication administration and interview on 10/22/2024 at 08:20 AM, MA H was observed to administer 1 (one) tablet of Vitamin D3 2000mg to Resident #16. MA H said the physician's order was for 2 tablets of Vitamin D3 1000mg. MA H said he did not have any Vitamin D3 1000mg tablets and said the 1 tablet of Vitamin D3 2000mg was the same thing. MA H did not consult the charge nurse about not having the prescribed 1000mg Vitamin D3 tablets nor did he seek the nurse's guidance for determining the number of tablets to give of the substituted medication. During this same observation of medication administration, MA H said he did not have the physician ordered Glipizide 2.5mg tablets (for treatment of Diabetes). He told LVN D who said she would look for the medication. The ADON came to the medication cart and pulled out a card of Glyburide 2.5mg tablets. MA H said the order was for Glipizide. The ADON put the Glyburide tablets back in the cart and said she would notify the pharmacy. Shortly after, the ADON returned to the cart and said the order for Glyburide was discontinued on 07/19/2024 and a new order for Glipizide was written the same day. The ADON said pharmacy would deliver the Glipizide that evening. A review of Resident #16's October 2024 physician orders indicated an order dated 06/19/2024 for Resident #16 to be given 2 (two) Vitamin D3 25mcg (1000 UT) capsules one time a day. The same physician orders also indicated an order dated 07/19/2024 to discontinue Glyburide 2.5 mg 1 tablet daily and start Glipizide 2.5mg 1 tablet daily. A review of the October 2024 MAR indicated Resident #16 was to receive Glipizide 2.5mg 1 tablet daily. A review of the MARs from 07/20/2024 through 10/21/2024 indicated Resident had received Glipizide 2.5mg daily. A review of Resident #16's medication labeled Glyburide 2,5mg tablets was noted filled by the pharmacy on 09/27/2024 and had 15 tablets missing from the card. A review indicated the following: *07/20/2024 a card containing 30 tablets each of Glyburide 2.5mg was delivered to the facility. *08/29/2024 a card containing 30 tablets each of Glyburide 2.5mg was delivered to the facility. *09/27/2024 a card containing 25 tablets of Glyburide 2.5mg was delivered to the facility. *09/30/2024- 5 tablets of Glyburide 2.5mg was delivered on 09/30/2024. Further review revealed there was no evidence the medication, Glipizide 2.5mg tablets, had ever been delivered to the facility. 2.A review of Resident #24's face sheet indicated he was [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included myasthenia gravis (a weakness and fatigue of muscles under voluntary control), sciatica (pain radiating along the sciatic nerve which runs down one or both legs from the lower back), vertebral low back pain, and chronic pain syndrome. During an observation of medication administration and interview on 10/22/2024 at 08:40 AM, MA H was observed to administer 1 (one) tablet of Vitamin C 500mg to Resident #24. MA H said the physician's order was for 2 (two) tablets of Vitamin C 250mg. MA H said he did not have any Vitamin C 250mg tablets and said the 1 (one)tablet of Vitamin C 500mg was the same thing and proceeded to administer the 1 (one) tablet of vitamin C. MA H did not consult the charge nurse about not having the prescribed 250mg Vitamin C tablets nor did he seek the nurse's guidance for determining the number of tablets to give of the substituted medication. During this same observation of medication administration, MA H said the physician's order was for 2 capsules of Gabapentin 100mg but the label on the bottle containing Gabapentin 100mg capsules said give 1 tablet. He asked the charge nurse, LVN D, about the conflicting labels. LVN D located a card of Gabapentin 100mg capsules with a label that matched the physician's order for 2 capsules to be given. MA H said he did not know if Resident #24 had been getting 1 (one) or 2 (two) capsules. A review of Resident #24's October 2024 physician's orders and MAR indicated an order dated 08/07/2024 to administer 2 Vitamin C 250mg tablets once a day. The same physician orders indicated an order dated 09/20/2024 for Resident #24 to be given 2 (two) Gabapentin 100mg capsules 3 (three) times daily. 3. A review of Resident #26's face sheet indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus. During an observation of Resident #26's insulin administration on 10/22/2024 at 11:30 AM, LVN D was observed to administer a subcutaneous injection of 15 units of insulin to Resident #26's right upper abdominal quadrant. Resident #26 was overheard to ask LVN D if she was going to rub it. LVN D replied she was and proceeded to massage the injection site. During an interview with LVN D on 10/22/2024 at 11:50 AM, LVN said massaging the site of an insulin injection was proper technique, then said, she was not supposed to massage the site of an insulin injection but because Resident #24 asked her to, she did. During an interview with the DON on 10/23/2024 at 01:45 PM, he said medication aides were not supposed to calculate drug dosages. He said MA H should not have made the decision to give different vitamins of different strengths without discussing it with the charge nurse and having the charge nurse determine the amount of each vitamin to give to meet the physician's order. The DON said Resident #24 probably brought the bottle of gabapentin capsules from home when he admitted to the facility and the bottle should not have been in the cart. He said someone should have noticed the discrepancy between the drugs, Glipizide and Glyburide. The DON said massaging the site of an insulin injection was not proper technique. The DON said he expected the medication aides to let the nurse know when medications were not available or when orders needed clarification. He said he expected medication aides to follow the rules of medication administration to ensure residents receive the right medication and he expected nurses to use proper technique when administering injections. A review of the facility's policy titled Pharmacy Services indicated the following: The facility will provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of the residents. Medications must be ordered and reordered on a timely basis so that no resident misses a dose. The facility will ensure drug administration processes are followed to ensure that: drugs to be administered are checked against the physician's orders. A review of the Texas Administrative Code:Title 26: Part 1: Chapter 557: Rule 557.105 indicated the following: A medication aide permitted under this chapter may not: (5) calculate residents' or client's medication dosages for administration . A review of the facility's policy titled Subcutaneous Injection Administration indicated the following: Procedure: 19. Cover site (injection) site with alcohol wipe. Massage site gently to distribute drug and facilitate absorption, except when giving heparin or insulin. A review of Lippincott's 2004Atlas of Medication Administration indicated the following: .For a subcutaneous injection, the site is gently massaged after the medication has been given, except in the case of heparin and insulin because massaging the site can increase the rate of absorption of these agents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 5 Residents (Residents #3, #7, #21) reviewed for medical records accuracy. The facility failed to ensure Resident #3's physician orders included orders for dialysis and the care of the dialysis access device. The facility failed to ensure Resident #7's physician orders included clear and precise instructions for the administration of an antidepressant medication. The facility failed to insure Resident #21's physician orders included the amount of an ordered liquid nutritional supplement to be given. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. Findings included: 1.A review of Resident #3's face sheet dated 10/25/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included End Stage Renal Disease (a condition in which the kidneys lose the ability to remove wastes and balance fluids) and Dependence on Renal Dialysis (a person requires regular dialysis to remove excess water and wastes to sustain their life). A review of Resident #3's quarterly MDS assessment (Section O:J1) dated 08/17/2024 indicated she had received dialysis during the observation period. The same MDS noted Resident #3 to have a BIMS score of 15 indicating her cognition was intact. A review of Resident #3's care plan dated 10/22/2024 indicated she was receiving dialysis and included interventions to address it. A review of Resident #3's physician orders indicated there were no orders for dialysis treatment nor a protective dressing to the shunt site. During an observation and interview with Resident #3 on 10/21/2024 at 10:30 AM, she said she went to dialysis 3 (three) days a week. While she was speaking, resident #3 pulled up the sleeve on her left arm and pointed to the dialysis shunt (access device) site area. The shunt site was clean and dry. There was no dressing or band aide covering the site. Resident #3 said the dialysis center puts a dressing on the site after the dialysis is complete. She said the dressing usually comes off by itself or becomes loose and she removes it. She said the facility did not put any covering over the site. During an interview on 10/23/2024 at 01:00 PM, LVN D said Resident #3 went to the dialysis center on Tuesday, Thursday, and Saturday every week. She said she would verify orders for dialysis and care of the shunt site by reviewing the physician's orders. LVN D said she could not find any orders for dialysis nor shunt site care. A review of the facility's policy titled Dialysis indicated the following: 1.Review and confirm the physician's order for dialysis. 7.The (access) site will be assessed .every shift. 10.If the dressing should become wet or be removed, put a clean band aid over the site 2.A review of Resident #7's face sheet dated 10/22/2024 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Anxiety, unspecified somatoform disorder (extreme focus on physical symptoms such as pain, weakness, shortness of breath), schizoaffective disorder, bipolar type, and schizoaffective disorder, depressive type (major mood disorder , either depression or mania, that occur at the same time as symptoms of schizophrenia are present). A review of Resident #7's admission MDS assessment dated [DATE] noted Resident #7 had a BIMS score of 10 indicating her cognition was moderately impaired. The same MDS indicated Resident #7 had received antidepressant medication during the observation period. A review of Resident #7's physician orders indicated the following: *Dated 04/22/2022 Venlafaxine 150mg to be given once a day with 75mg to equal 225mg. *Dated 07/27/2024 Effexor 150mg to be given once a day (Venlafaxine is the generic form of Effexor). A review of a PMHNP (Psychiatric Mental Health Nurse Practitioner) record for Resident #7 dated 07/19/2024 noted a plan to increase Effexor to 150mg daily. The same record noted Resident #7 was currently receiving Venlafaxine (Effexor) 75 mg with 150mg to equal 225mg. A review of a PMHNP record dated 07/23/2024 noted Resident #7's current medications included Venlafaxine 75mg 1 (one) time a day with 150mg to equal 225mg and Effexor 150mg 1 (one) time a day. The same record included notation saying Effexor had been increased to 150mg a day on 07/19/2024. A review of the October 2024 MAR for Resident #7 indicated the following: * 1 (one) capsule of Venlafaxine 150mg to be administered with 75mg to equal 225mg every day. * Effexor (venlafaxine) 150 mg to be administered one time a day. Further review of the October 2024 MAR indicated both orders had been signed by staff, indicating Resident #7 had received 375mg of Venlafaxine every day since 07/27/2024. Observation of the medication cart on 10/23/2024 at 2:05 PM noted Resident #7 had 2 (two) medication cards containing Venlafaxine. * Card 1-Venlafaxine capsule 75mg: Give 1 (one) capsule by mouth once daily with 150mg for total dose of 225mg per day. * Card 2-Venlafaxine 150mg: Give 1 (one) capsule daily with 75mg for total dose of 225mg per day. During an interview with Resident #7 on 10/22/2024 at 10:15 AM, she did not know what medications she took or why. Resident was noted to be calm and showed no signs of mental upset. During an interview with the ADON, DON, and RN G present on 10/23/2024 at 02:10 PM, the ADON said she understood Resident # 3 was supposed to be given a total of Venlafaxine 375mg daily. The DON said he understood Resident #3 was to receive 225mg of Venlafaxine daily. He said the orders should have been written so that whoever was administering meds would know to give a 150mg capsule and a 75mg capsule and there would be a space to sign for the administration of each capsule. He said he did not know why the PMHNP would document to increase the dose of Venlafaxine to 150mg when Resident #7 was receiving 225mg of Venlafaxine at the time she prescribed the increase. RN G said the orders were not clear and should be clarified. During an interview with the DON on 10/23/2024 at 02:35 PM, he said he found where Resident's order for 75mg Venlafaxine was discontinued on 02/22/2024 and the order for Venlafaxine 150mg daily continued. He said the instructions to give with 75mg to equal 225mg should have been removed from the instructions. He said the PMHNP would be at the facility shortly and he would ask about the noted instructions to increase the Effexor dose to 150mg daily. The DON also said part of the confusion could be due to the use of the generic drug name used in some orders and the brand name used in other orders even though both names refer to the same drug. During an interview with the PMHNP on 10/23/2024 at 03:10 PM, the PMHNP said she increased the Venlafaxine dose by an additional 150 mg to total 300mg daily. The DON was overheard to ask the PMHNP if it would be better to write the order to give 2 Venlafaxine 150mg capsules at which the PMHNP said that was ok. The PMHP said the pharmacist should have addressed this. During an interview on 10/23/2024 at 04:05 PM, the DON said he did not know why the issue with the Venlafaxine orders had not been addressed. He said he did not know why the card of Venlafaxine 75mg capsules were not removed from the cart when it was discontinued. He said he did not know why the discrepancies between the PMHNP records, physician orders, MAR records, and labels on the medication containers had not been noticed and addressed. The DON said there was a risk of overdosing and/or underdosing of medication due to unclear orders. He said he expected the nurses and med aides to notify him of all unclear orders. 3.A review of Resident #21's face sheet dated 10/22/2024 indicated she was a [AGE] year-oldfemale who admitted to the facility on 0323/2024 with diagnoses which included dementia and protein calorie malnutrition. A review of Resident #21's MDS dated [DATE] noted her to be rarely understood by others. A review of Resident#21's care plan dated October 2024 indicated she was at risk for weight changes and malnutrition. A review of Resident #21's weight records from April 2024 through October 2024 indicated Resident #21 had a mild weight loss of approximately 4.5 pounds over the last 6 months. A review of the physician's orders dated 10/22/2024 indicated Resident #21 was to receive Med Pass 2.0 (a liquid nutritional supplement that provides 120 calories and 5 grams of protein in each 2 oz. serving) 2 (two) times daily for weight loss. The order did not specify the amount of the supplement to be given with each administration. A review of the October 2024 MAR indicated Resident #21 was provided Med Pass 2.0 twice daily. There was no documentation to reflect how much supplement was provided nor how much Resident #21 consumed. During an interview on 10/23/2024 at 02:20 PM, MA J accessed Resident #21's MAR and said the order did not say how much Med Pass 2.0 to give Resident #21. MA J said whenever she saw Med Pass 2.0 on the MAR, she gave about half of a disposable cup she was holding in her hand. The cup was a 6oz cup. She said she had not consulted the charge nurse nor the DON about the incomplete order. She said Med Pass 2.0 was given to residents who were losing weight. During an interview with the DON on 10/23/2024 at 04:00 PM, he said he was not aware the order for Med Pass 2.0 did not specify the amount to be given. He said he expected the medication aides to notify the charge nurse, ADON, or himself when orders needed clarification. A review of the facility's policy titled Pharmacy Services indicated the following: The facility will provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of the residents. The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.The pharmacist must report any irregularities to the medical director, attending physician and the director of nursing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for adequate supervision. The facility failed to ensure hospice staff were informed of Resident #1's need for a cup with a lid and supervision when provided coffee. The facility failed to ensure facility staff were aware of Resident #1's need for a cup with a lid when provided coffee. The facility failed to have a method or form of communication to ensure all staff were aware of Resident #1's need for a cup with a lid and supervision when provided coffee. The facility failed to ensure Resident #1's meal ticket was updated to indicate the need for a cup with a lid for hot liquids. The facility failed to complete a new Hot Liquid Assessment after the hot coffee spill on 12/12/2023. These failures could place residents at risk for injury or decline in health. Findings included: During an observation and interview on 12/23/2023 at 07:50 AM, Resident # 1 was observed to be lying in bed with the head of the bed elevated to approximately 90 degrees. Resident #1 was observed to be eating her breakfast independently. Drinks on the tray included cranberry juice and water. There was no coffee. When asked if she wanted coffee, resident said she did not want coffee right now. Resident was observed to drink the juice without any difficulty. A meal ticket on her tray with her name on it indicated resident #1 required no special considerations or devices. Record review of a face sheet dated 12/23/2023 indicated Resident #1 to be a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebrovascular disease (a group of conditions that affect blood flow and blood vessels in the brain), cognitive impairment, chronic obstructive pulmonary disease, and breast cancer. Record review of a MDS dated [DATE] indicated Resident #1 to be rarely/never understood on her BIMS assessment. The same MDS indicated resident required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs, or other non-weight-bearing assistance) with eating. Record review of a Hot Liquid assessment dated [DATE] and completed by the DON, indicated Resident #1 was not able to hold hot liquids in a cup or bowl without difficulty, had tremors to upper body area, needed assistance with eating, and tremors were worse some days more than others. The interventions section of the Hot Liquid Assessment indicated Resident #1 was safe to drink hot liquids without assistance using a cup with a lid. The latter part of this section indicated resident required assistance while drinking hot liquids from a cup with a lid. Record review of a care plan initiated on 02/24/2022 indicated Resident #1 required set-up help, supervision, verbal cueing, and physical assistance as needed with eating. The care plan did not include any directions for a cup with lid (sippy cup) for hot liquids. Record review of nurses' notes written by LVN E and dated 12/12/2023 at 11:54 AM indicated the Hospice Chaplain gave Resident #1 a cup of coffee and a few minutes later, Resident #1 spilled the coffee onto her left leg. The notes indicated facility staff responded immediately, took Resident #1 to her room, removed her pants, and applied cool compress to the left thigh. The area was described as a red streak down the left thigh with no blistering and no reported pain. Review of nurses' notes written by LVN C and dated 12/13/2023 at 08:34 AM indicated a description of the left thigh as having a pale pink, thin line with no blistering and no reported pain. A record review of the Hospice Notebook for Resident #1 did not indicate a care plan nor any instructions in regard to Resident #1's care. There was no indication of Resident #1's need for supervision nor a cup with a lid for drinking hot liquids. During an interview with Non-Certified Aide A on 12/23/2023 at 08:20 AM, she said the staff knew who to give cups with lids to because it was on the residents' meal tray tickets. Aide A said coffee comes out in a carafe with the meal trays and the staff delivering the trays refer to the meal ticket for instructions on preferred drinks and assistive devices. She said the facility used sippy cups (a 2-handled cup with a lid that has a spout to sip from)) for residents who were at risk to spill their drinks. She did not know how hospice staff or visitors would know if a resident required assistive devices for drinking coffee. During an interview with Non-certified Aide B at 08:35 AM, she said the meal tickets come out with the trays. She said the meal tickets tell the staff what the resident is supposed to have with their meals. She said Resident #1 did not need anything special to drink her coffee but since she spilled coffee on herself a couple of weeks ago, someone watches her when she is drinking coffee. During observation and interview on 12/23/2023 at 09:30 AM, LVN C, was observed to assist Resident #1 to turn toward her ride side to expose the resident's left thigh. LVN C pointed to the area where coffee spilled onto the resident's thigh. No evidence of a burn, red, or open areas were noted. A faint, light tan line approximately 3.0x0.3 cm was noted to the left, lateral distal thigh. Resident denied any pain when area was touched by LVN C. LVN C said the area had not required any treatment nor had Resident #1 required any pain medication because of the coffee spill. During an interview with LVN C on 12/23/2023 at 09:40 AM, she said hospice staff use electronic devices to refer to for resident care information. She said as far as she knew, the facility nursing staff did not have access to the information on those devices. She said the information the facility had was in individual notebooks at the nurses' station. During an interview with the DON and ADON on 12/23/2023 at 09:50 AM, the DON said hospice staff had not been told Resident #1 required specific devices for drinking coffee because a Hot Liquid Assessment completed on 11/19/2023 indicated Resident #1 could manage hot liquids without any assistive devices. The DON said there were no residents who used lids on their cups. During an interview with the DM on 12/23/2023 at 10:00 AM, she said she was responsible for ensuring meal tickets included information specific to each resident including any assistive devices to be used. She said she was not aware that Resident #1 required any assistive devices. The DM said the facility did not have any lids for the coffee cups. She said the facility had sippy cups for residents who are at risk for spilling hot liquids. During an interview with ADM on 12/23/2023 at 11:00 AM, she said the facility does not use lids for their coffee cups. During a phone interview with Hospice Chaplain D on 12/23/2023 at 11:11 AM, she said that on 12/12/2023, she wheeled Resident #1 to a table in the dining room and gave her a half cup of coffee because she knew the resident's hands shook some. She said she went to visit another resident in the dining room and after about 10 minutes, she looked over at Resident #1 and saw her push herself away from the table, pick her coffee cup up from her lap and throw it to the floor. She said she went to Resident #1, saw that she had spilled her coffee, lifted the pant leg away from the thigh, and held it while she called for help. She said the pants did not feel hot and the resident denied any pain. She said she was not aware Resident #1 was to have a lid on her coffee cup. During a phone interview on 12/23/2023 at 11:28 AM with LVN E, she said the Medication Aide made her aware that Resident #1 had spilled her coffee onto her leg. She said she and the medication aide took Resident #1 to her room, removed her pants, and saw a pink, non-blistering line down her left lateral thigh. She said she applied a cold compress to the area and notified the nurse practioner, Hospice Nurse on call, and the family. During an interview with DON on 12/23/2023 at 1:44 PM, he said hospice staff are invited to the care plan meetings but do not always come. He said the 11/19/2023 Hot Liquid Assessment that indicated Resident #1 was capable of handling hot liquids in a cup was correct. He said the 11/29/2023 Hot Liquid Assessment that indicated Resident #1 was to have a cup with a lid and supervision when drinking hot liquids was incorrect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and permitted only authorized personnel to have access to the keys for 1 of 2 rooms (medication room and DON office) used for storage of medications and other biological chemicals. The facility failed to ensure the DON's office located on Hall D was secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for medication misuse, medication diversion, and injury related to ingestion or use of biological chemicals. Findings included: During an observation on 09/12/2023 at 12:05 PM, the following items were noted on open shelves on a wall in the DON's office: 16 bottles (100 tablets each) of Vitamin D3 25 mcg, 1 bottle (100 tablets) [NAME] 500mg Extra Strength Aspirin, 1 unopened box containing 300 cough suppressant lozenges, 1 bottle (16 oz) Dakins Solution (wound cleaner containing sodium hydrochloride), 1 bottle (12oz) Hydrogen Peroxide, 16 bottles (32oz size) hand sanitizer refill solution, 1 partially used plastic container of Drug Disposal (for disposing of drugs), and 10 tubes A&D ointment, and 1 bottle (24 oz) Acaricid (surface disinfectant cleaner). The door to the DON's office was open and nobody was in the office. During an observation on 09/13/2023 at 09:40 AM, the door to the DON's office was noted open and nobody was in the office. The same items were noted on the open shelves. There were 2 residents in wheelchairs on the hall. During an interview with the DON at 1:40 PM on 09/13/2023, the DON said the items on the shelves had probably been there since he came in March, 2023. He said he had planned to take the shelves down. The DON stated these items were accessible to residents and should be in a secure location and not available to unauthorized persons. Record review of the facility's undated policy titled Storage of Medications indicated the facility's purpose was to ensure that medications are stored in a safe, secure, and orderly manner. 6. Compartments containing medications are locked when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 12 residents reviewed for medication storage (Resident #15). The facility did not ensure Resident # 15's medications were kept in a secured location. Resident #15 had 2 bottles of the over-the-counter medication Bio-Freeze at her bedside. This failure could place residents at risk for overuse and adverse effects of medication and harm. Findings included: Record review of consolidated physicians' orders dated 8/10/2022, indicated Resident #15 was [AGE] years old, admitted on [DATE] and had diagnosis including lack of coordination, anxiety, essential tremor, dementia, muscle weakness, pain, and arthritis. There was no order for Bio-Freeze (used to treat minor aches and pains of the muscles and joints) and no orders for self-administration of medications. Record review of the most recent comprehensive MDS dated [DATE], indicated Resident #15 usually made herself understood and usually understood others. The MDS indicated Resident #15 had a BIMS (brief interview for mental status) score of 12. The MDS indicated Resident #15 required extensive assistance with bed mobility, transfers, dressing and personal hygiene. The MDS indicated Resident #15 was dependent with toileting and locomotion on and off the unit. Record review of the care plan dated 6/16/2022, indicated Resident #15 was at risk for pain and had interventions including non-pharmacological pain relief measures, encourage resident to verbalize pain at onset, observe for non-verbal signs of pain and provide as needed medications as indicated. The care plan indicated Resident #15 had a diagnosis of dementia. During an observation on 8/9/2022 at 1:40 p.m. a bottle of Bio-Freeze was observed on Resident #15's bedside table. During an observation and interview on 8/9/2022 at 2:55 p.m., a bottle of Bio-Freeze was observed inside the open top drawer of the bedside table next to Resident #15's bed within her reach and one on top of the overbed table within her reach. Resident #15 said she used the Bio-Freeze when she could get someone to put it on her. She said she used it for the pain in her shoulders and sometimes needed help to reach the right spot. Resident #15 said staff had assisted her to put this on a few minutes ago but could not recall who the staff was. During an observation on 8/10/2022 at 9:05 a.m., Resident #15 had two bottles of Bio-Freeze within her reach. One bottle on the over bed table and one bottle inside the open top drawer of her bedside table. Resident #15 said she had her family purchase and bring the Bio-Freeze to help with her arthritis pain. During an interview on 8/10/2022 at 10:45 a.m., LVN A said any prescriptions or over the counter medications had to have an order from the physician to be kept at the bedside. LVN A said medications kept at the bedside without an order could lead to overuse or misuse of the medication. LVN A said she had not been made aware of the Bio-Freeze at Resident #15s bedside and she did not have an order for it to be at her bedside. LVN A said they would have to talk to Resident #15 and remove the medication until an order was received to have at the bedside. During an interview on 8/10/2022 at 10:45 a.m., MA B said medications could not be left at the residents' bedside without an order. MA B said this could lead to overuse of the medication by the resident. MA B said she was not aware of any Bio-Freeze in the residents' room and wound notify the charge nurse immediately. During an interview on 8/10/2022 at 11:30 a.m., the administrator said medications could not be left at the bedside without an order to do so. The administrator said the facility had other residents who wander and could come in and find the medication and could put in their mouth. The administrator said she expected staff to look for these types of items in the room daily during their rounds and remove any medications without an order to be in the room. Record review of an undated policy titled Medication Self-Administration indicated residents are not permitted to administer or retain any medications in his or her room unless their attending physician writes an order for self-administration of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of consolidated physicians' orders dated 8/10/2022, indicated Resident #15 was [AGE] years old, admitted on [DATE] and had diagnosis including COPD (chronic obstructive pulmonary disorder), anxiety, essential tremor, dementia, muscle weakness, pain, and arthritis. The orders indicated Resident #15's oxygen humidifier should be changed every week on Sundays. Record review of the most recent comprehensive MDS dated [DATE], indicated Resident #15 usually made herself understood and usually understood others. The MDS indicated Resident #15 had a BIMS (brief interview for mental status) score of 12. The MDS indicated Resident #15 required extensive assistance with bed mobility, transfers, dressing and personal hygiene. The MDS indicated Resident #15 was dependent with toileting and locomotion on and off the unit. Record review of the care plan dated 6/16/2022 did not address Resident #15's oxygen concentrator or humidifier. During an observation on 8/9/2022 at 1:40 p.m., Resident #15 was in bed wearing her oxygen canula with the oxygen concentrator on. Resident #15's oxygen humidification bottle was dated 7/25/2022. During an observation and interview on 8/9/2022 at 2:55 p.m., Resident #15 said the staff assisted her with her oxygen and nebulizer equipment care. Resident #15's oxygen humidification bottle was dated 7/25/2022. During an observation on 8/10/2022 at 9:05 a.m., Resident #15 was resting in her bed with her oxygen canula on and the humidification bottle on the concentrator was dated 7/25/2022. The oxygen concentrator was turned on. Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 2 residents reviewed for respiratory care. (Residents #6 and 15). The facility failed to change the oxygen humidifier bottle and water for Resident #6 and Resident #15. These failures could place residents who required respiratory care at risk for respiratory infections. Findings included: 1. Record review of the face sheet dated 08/10/22 indicated Resident #6 was an [AGE] years old female admitted on [DATE] with diagnoses of COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), Heart Failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood), and Hypertension (Blood pressure is the force that a person's blood exerts against the walls of their blood vessels). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #6 usually made herself understood and others. Resident #6 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated she had moderately impaired cognition. The MDS indicated Resident #6 required extensive assist with bed mobility, dressing, toileting, personal hygiene, and bathing. The MDS indicated that Resident #6 had COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing) and required oxygen. Record review of the care plan dated 07/19/22 for Resident #6 indicated a diagnosis of COPD and to implement appropriate ordered intervention. Record review of the Physician order dated 02/21/22 indicated Resident #6 had an order to change oxygen tubing and water one time a week on Sunday. Physician order dated 04/07/22 indicated Resident #6 had an order for oxygen at 2-3 liters continuously related to COPD. During an observation on 08/08/22 at 11:09 a.m., Resident #6 was in in bed wearing a nasal cannula. The nasal cannula was attached to a humidified water bottle filled with water connected to an oxygen concentrator. The oxygen concentrator was on and running at 2 liters of oxygen. The humidified water bottle was dated 07/25/22 and the label indicated for single use only. During an observation on 08/09/22 at 3:50 p.m., Resident #6 was in bed wearing a nasal cannula connected to an oxygen concentrator with humidified water. The oxygen concentrator was on and running at 2 liters of oxygen. The humidified water bottle was dated 07/25/22 and the label indicated for single use only. During an observation on 08/10/22 at 9:10 a.m., Resident #6 was in bed wearing a nasal cannula connected to an oxygen concentrator with humidified water. The oxygen concentrator was on and running at 2 liters of oxygen. The humidified water bottle was dated 07/25/22 and the label indicated for single use only. During an interview on 08/10/22 at 01:10 p.m., LVN A said night shift nurses were supposed to change oxygen tubing and humidified water every Sunday night and dated. LVN A said Resident #6 and Resident #15 used oxygen and humidified water. LVN A said Resident #6 and Resident #15's humidified water bottle was dated 07/25/22. LVN A said she worked the night shift on 07/25/22 and she was the last one to change Resident #6 and Resident #15's humidified bottles because the dates on the bottles were written by her. LVN A said they had no clean humidified water bottles at the facility because they changed supply companies a couple weeks ago and they have not been delivered yet. LVN A said they are refilling Resident #6 and Resident #15's humidified water bottles until they get some. LVN A said she did not realize Resident #6 and Resident #15's humidified water bottles said, for single use only and should not be refilled. LVN A said if oxygen tubing and humidified water are not changed weekly bacteria could grow and place a resident at risk for a respiratory infection. LVN A said Resident #6 and Resident #15's oxygen tubing and humidified water bottle had not been changed and they were at risk for a respiratory infection. During an observation on 08/10/22 at 01:59 p.m., there were no prefilled or disposable humidified water bottles in the supply room. During an interview on 08/10/22 at 02:09 p.m., the administrator said the DON was responsible for ordering supplies but was on vacation, so she was responsible until her return. The administrator said they changed supply companies about a week and a half ago and she had ordered humidified water bottles sometime last week. The administrator said she was not aware of any supplies on back order and the humidified water bottles should have been delivered but did not know for sure. The administrator said she expected the night shift nurses to change and date the oxygen tubing and humidified water every Sunday night. The administrator said she was not aware the oxygen tubing for Resident #6 and Resident #15 was not dated and their humidified water was dated 07/25/22. The administrator said if oxygen tubing and humidified water are not changed weekly bacteria growth can occur and place a resident at risk for a respiratory infection. The administrator said Resident #6 and Resident #15 were at risk for a respiratory infection and their oxygen tubing and humidified water should be changed and dated to prevent infection. Record review of the facility Oxygen Administration policy undated indicated, .1. Check physician's order for liter flow and method of administration .5. Prefilled, sealed, disposable humidifiers may be changed per facility procedure .g. Label humidifier with date and time opened. Change humidifier and tubing per facility procedure .