**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of a section contained within the facility's Privacy Notice (admission Packet) titled, . RESIDENTS' RIGHTS AND RESPONSIBILITIES OF FACILITIES ., the facility failed to ensure Resident Identifier (RI) #40 and RI #44 had a choice in choosing their representative /responsible party. This deficient practice affected RI #'s 40 and 44, two of 41 sampled residents. Findings include: A review of the facility's Privacy Notice, with an effective date of 04/14/2003, contained the following information: . RESIDENTS' RIGHTS AND RESPONSIBILITIES OF FACILITIES . The management and staff of their center will make every effort to assist you in exercising your Residents' Rights. 8. Freedom of Choice-The right to choose a personal attending physician, to be fully informed on advance about care and treatment, to be fully informed in advance of any changes in care or treatment that may affect the resident's well-being, . 1) RI #40 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Unspecified Dementia and Cognitive Communication Deficit. A review of RI #40's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/04/2024, revealed RI #40 had a Brief Interview for Mental Status (BIMS) score of 00 of 15 indicating severe cognitive impairment. A review of RI #40's face sheet revealed there was no representative/responsible party listed and the Administrator (ADM) was listed as RI #40's second contact. 2) RI #44 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of Alzheimer's Disease with Late Onset. A review of RI #44's MDS assessment, with an ARD of 11/09/2023, reveled RI #44 had a BIMS scord of two of 15, indicating RI #44 had severely impaired cognition. RI #44's face sheet revealed the ADM was listed as RI #44's representative /responsible party. On 02/09/2024 at 8:23 AM, a telephone interview was conducted with the Ombudsman (OMB) [advocate for the residents]. The OMB stated he was not aware the ADM was the representative/responsible party for RI #40 and RI #44; and he had never heard of an ADM being a representative/responsible party for a resident. On 02/09/2024 at 9:05 AM, an interview was conducted with the Social Service Director (SSD). The SSD stated the ADM had been RI #40's and RI #44's representative/responsible party since their admissions. On 02/09/2024 at 12:04 PM, an interview was conducted with the Assistant Administrator (AADM ). When asked who was RI #40's and RI #44's representative/responsible party, the AADM stated the ADM. The AADM stated the facility decided the ADM would be the representative/responsible party for RI #40 and RI #44. The AADM said she did not remember attempting to contact the Ombudsman nor had the facility contacted an attorney yet, to help with obtaining a representative/responsible for RI #40 and RI #44. The AADM said she did see the conflict with the ADM being the representative/responsible party for RI #40 and RI #44. On 02/09/2024 at 1:52 PM, an interview was conducted with the ADM. When asked how long he had been RI #40's representative/responsible party, the ADM said he was RI #40's second contact. When asked who decided he would be the second contact, the ADM said he stepped up and said he would be the contact person. When asked if he had contacted the Ombudsman for guidance on finding a representative /responsible for the resident, the ADM stated he had not. The ADM also said he had been the responsible party for RI #44 since RI #44's admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of a section contained within the facility's Privacy Notice (admission Packet) titled, . RESIDENTS' RIGHTS AND RESPONSIBILITIES OF FACILITIES ., the facility failed to ensure Resident Identifier (RI) #2's and RI 40's listed responsible parties signed the consent for the residents to received the COVID-19 vaccination. This deficient practice affect RI #2 and RI #40, two of 41 sampled residents. Findings include: A review of the facility Privacy Notice, with an effective date of 04/14/2003, contained the following information: . RESIDENTS' RIGHTS AND RESPONSIBILITIES OF FACILITIES . The management and staff of their center will make every effort to assist you in exercising your Residents' Rights. 8. Freedom of Choice- . to be fully informed on advance about care and treatment, to be fully informed in advance of any changes in care or treatment that may affect the resident's well-being, . RI #2 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #2's face sheet revealed the responsible party was the resident's daughter. A review of RI #2's Vaccine Administration Record (VAR), dated 11/14/2023, revealed the Administrator (ADM) and not the resident's responsible party signed for the authorization for RI #2 to receive the COVID-19-vaccination. On 02/09/2024 at 1:52 PM, an interview was conducted with the ADM. When asked who signed RI #2's COVID-19 vaccination consent on 11/14/2023, the ADM stated he did. The ADM was asked if he had power of attorney (POA) for RI # 2's medical care. The ADM said no, he did not. RI #40 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #40's VAR, dated 12/04/2023, revealed the Assistant Administrator (AADM) not the resident's second contact person (the ADM) signed for the authorization for RI #40 to receive the COVID-19 vaccination. On 02/09/2024 at 12:04 PM, an interview was conducted with the AADM. The AADM stated that the consent form for RI #40 would have to be signed by the physician, but she signed the consent form for RI #40 to receive the COVID-19 vaccination. The AADM said she should not have signed RI #40's consent form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of Resident Identifier (RI) # 40's and RI #44's Care Plan Review sheets, there was no evidence the Administrator (ADM) who was identified as the second contact/responsible party attended the care plan meetings. This deficient practice affected RI #40 and RI #44, two of 41 sampled residents Findings include: RI #40 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #40's face sheet revealed there was no responsible party listed and the Administrator (ADM) was listed as the second contact. On review of RI #40's Care Plan Review sheets dated 04/20/2023, 07/13/2023, 10/12/2023 and 01/11/2024, there was no evidence RI #40 had a representative/responsible party at these care plan meetings. RI #44 was admitted to the facility on [DATE] and readmitted on [DATE] A review of RI #44's face sheet revealed the responsible party was the ADM. On review of RI #44's Care Plan Review sheets dated 01/26/2023, 04/20/2023, 07/20/2023, 08/17/2023, and 11/16/2023, there was no evidence RI #44 had a representative/responsible party at these care plan meetings. On 02/09/2024 at 9:05 AM, an interview was conducted with the Social Service Director (SSD). When asked who signs the Care Plan Review sheets, the SSD said the people (staff) who attends the meetings. On 02/09/2024 at 1:52 PM, an interview was conducted with the ADM. When asked what days for the last year had he signed that he attended a care plan meeting for RI #40 and RI #44, the ADM stated he had not signed any of them indicating he had attended. On 02/09/2024 at 4:50 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked how would she know who attends the care plan meeting. The DON said the SSD should have it documented. When asked was it documented that the ADM attended RI #40's care plan meeting for the last year, the DON said no. The DON was asked was there documentation that the ADM attended RI #44's care plan meeting in the past year. The DON said, no she did not see the ADM's name on the Care Plan Review sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, interviews, record review and review of a facility policy titled, Administration of medication, the facility failed to ensure the EMAR (electronic Medication Administration Record) screen was closed, and did not reveal information about Resident Identifier (RI) #77's medications. This deficient practice affected RI #77, one of one resident; and was observed on 02/05/2024, during the evening medication pass. Finding include: Review of a facility policy titled, Administration of medication, with an effective date of 05/11/2023, revealed the following; . PROCEDURE . 23. Resident's health information needs to remain private. The pages of the EMAR containing resident health information must have privacy screen up when not in direct use . RI #77 was admitted to the facility on [DATE] with diagnoses to include Type II Diabetes Mellitus with Hyperglycemia, Constipation and Chronic Pain due to Trauma. RI #77's February 2024 Physician Orders revealed RI #77 was receiving Senna 8.6 mg (milligrams) by mouth twice a day for the Constipation, Acetaminophen (Tylenol) 325 mg, two by mouth, three times a day for the Chronic Pain, and Metformin 500 mg by mouth one every day for his/her diabetes. On 02/05/2024 at 4:13 PM, the surveyor observed that the privacy screen to the EMAR on top of a medication cart was not closed. RI #77's name was visible; and three medications, Tylenol, Senna, and Metformin was visible on the EMAR screen. Licensed Practical Nurse (LPN) #11 returned to the medication cart and was asked what type of concern it would be when the privacy screen was left opened and anyone passing by could view information on the screen. LPN #11 said it would be a HIPPA (Health Insurance Portability and Accountability Act) concern. When asked why it would be important to ensure the EMAR screen was closed, LPN #11 said so anyone who walked by would not see the patient's (resident's) information. On 02/09/2024 at 2:08 PM, an interview was conducted with the Registered Nurse (RN)/Unit Manager. When asked what position should the EMAR screen be in when the nurse was away from the medication cart, the RN Unit Manager said the security screen should be used which concealed the resident's information. The RN Unit Manager said it would be a HIPPA violation when the EMAR screen was left visible and revealed a resident's information. The RN Unit Manager said it would be important for the EMAR screen to be closed when the nurse was away from the medication cart to ensure privacy and confidentiality was maintained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of a facility policy titled, RESTRAINT and review of a facility form titled, PHYSICAL RESTRAINT CONSENT, the facility failed to ensure Resident Identifier (RI) #54 did not have all four side rails up when observed in bed on 02/08/2024. This deficient practice affected RI #54; one of one resident sampled for the use of restraints. Findings include: A review of a facility policy titled, RESTRAINT, with an effective date of 04/20/2009 revealed the following: POLICY . It is the policy . that no residents shall be restrained for discipline or convenience . A review of an undated facility form titled, PHYSICAL RESTRAINT CONSENT, revealed the following: . Side rails sometimes restrain residents. The use of side rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms . RI #54 was readmitted to the facility on [DATE] with a diagnosis of Dementia. A review of RI #54's SIDERAIL ASSESSMENT, dated 05/18/2023, revealed the following: ½ side rails up x (times) 2 to assist with bed mobility and positioning . A review of RI #54's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 11/21/2023, revealed RI #54 scored a six of 15 on the Brief Interview for Mental Status indicating RI #54 had severely impaired cognition, had no impairment to the upper and lower extremities and was not coded as utilizing a restraint during this assessment period. On 02/08/2024 at 11:40 AM, RI #54 was observed by the surveyor in bed with all four side rails in the up position. On 02/08/2024 at 11:44 AM, an interview was conducted with Certified Nursing Assistant (CNA) #19. When asked if RI #54 ever tried to get out of bed, CNA #19 stated yes, RI #54 could sling his/her legs over the side rails. CNA #19 said, when RI #54 was confused, he/she would try to get up sometimes. CNA #19 said RI # 54 was a fall risk. When asked why RI #54 had all four side rails up, CNA #19 stated she guessed for RI #54's fall prevention. On 02/08/2024 at 1:01 PM, the surveyor observed RI #54 in bed with all four side rails up. On 02/08/2024 at 3:37 PM, the surveyor again observed RI #54 in bed with all four bed rails up. On 02/08/2024 at 4:09 PM, Restorative Licensed Practical Nurse (LPN) #5 was interviewed and asked how many side rails did she observe up on RI #54's bed. LPN #5 said she observed four side rails up and there should have only been two side rails up. When asked why was there four side rails up, LPN #5 stated she was not sure because there should only be two up (the upper rails). When asked what the concern was with the four side rails being up, LPN #5 said it could be considered a restraint and RI #5 could hurt him/herself. On 02/09/2024 at 9:36 AM, the surveyor conducted an interview with the Director of Nurses (DON). When asked what type of side rails RI #54 should have, the DON said half side rails up time two. The DON further said, the concern with having the four side rails up would be restriction of RI #54.

Based on observations, interviews, record review, and review of a facility policy titled, FINGERNAIL AND TOENAIL CARE, the facility failed to ensure Resident Identifier (RI) #70's toenails and fingernails were kept clean and cut. This deficient practice affected RI #70 one of one resident who was sampled for Activities of Daily Living Care. Findings include: A review of a facility policy titled, FINGERNAIL AND TOENAIL CARE, with a reviewed date of 01/31/2023 revealed: . POLICY . It is the policy . to ensure that the resident's nails are clean, and to protect the resident from scratches from long fingernails/toenails. PROCEDURE . 3. Trim the fingernails/toenails using a nail clipper . 4. File the rough edges . RI #70 was admitted to facility on 10/26/2023 with a diagnosis of Cerebrovascular Disease, Unspecified. On 02/07/2024 at 9:05 AM, the surveyor observed that RI #70's toenails on his/her right and left big toes were very long. Also RI #70's fingernails were long, and the first finger nail on RI #70's right hand was broken with a sharp edge. RI #70 stated he/she wanted his/her nails cut but was told by a staff member that state would not allow them to cut his/her nails. On 02/07/2024 at 9:46 AM an interview was conducted with Certified Nursing Assistant (CNA) #15. CNA #15 stated the CNA's were responsible for cutting nails, which was done once or twice a month for female residents. CNA #15 was asked when would RI #70's nails be cut. CNA #15 stated she was not sure. On 02/07/2024 at 10:24 AM, the Director of Nursing (DON) said that since RI #70 had a diagnosis Type II Diabetes, the nurses would be required to provide nail care for RI #70. On 02/07/2024 at 10:36 AM, the surveyor and Licensed Practical Nurse (LPN) #18 entered RI #70's room for observation of RI #70's finger and toenails. LPN #18 was asked what would she say about RI #70's fingernails and toenails. LPN #18 stated RI #70's fingernails and toenails were long. LPN #18 further stated RI #70's fingernails and toenails needed to be cut. When asked when was the last time RI #70 had his/her fingernails and toenails cut, LPN #18 stated she was not sure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, resident record review, review of the Reference Manual for Cleaning and Disinfecting the Assure Prism Multi Glucometer and review of a facility policy titled, Hand Hygiene, the facility failed to ensure: 1) Licensed Practical Nurse (LPN) #7 effectively cleaned and disinfected the glucometer after obtaining a blood glucose check for Resident Identifier (RI) #36, 2) LPN #7 implemented Enhanced Barrier Precautions before entering the room of RI #46, which was clearly identified for the use of Personal Protection Equipment (PPE); and LPN #7 washed or sanitized her hands between touching RI #46 and RI #57. These deficient practice affected LPN #7, one of two licensed staff observed performing finger stick blood glucose monitoring; and LPN #7 one of one staff observed not applying PPE when entering an Enhanced Barrier Precaution room to provide personal care for RI #46, and failing to sanitize her hands in between caring for RI #46 and RI #57. Findings include: 1) A review of the reference manual for the cleaning and disinfecting of the Assure Prism Multi Glucometer revealed the contact time for the use of the Super Sani-Cloth Germicidal Disposable Wipe was two (2) minutes. (Contact time is the amount of time a disinfectant needs to sit on a surface, without being wiped away or disturbed, to effectively kill germs.) RI #36 was admitted to the facility on [DATE] with diagnosis of Type II Diabetes Mellitus without complications. RI #36's February's 2024 physician orders revealed, RI #36 received blood glucose monitoring twice a day. On 02/08/2024 at 4:07 PM, LPN #7 was observed performing a blood glucose check for RI #36. LPN #7 returned to the medication cart and wiped the glucometer for 38 seconds with a Super Sani-Cloth wipe; then placed the glucometer on a clean white barrier on top of the medication cart and dried glucometer with tissue as she stated, we have to let it air dry. On 02/08/2024 at 04:13 PM, an interview was conducted with LPN #7. LPN #7 was asked what was the process of cleaning the glucometer. LPN #7 replied, make sure it is cleaned with a wipe; and cleaned for three to four minutes. LPN #7 was asked, did she wipe the glucometer for the complete contact time. LPN #7 replied, no she did not. LPN #7 was asked, how long was she supposed to clean a glucometer. LPN #7 replied, two minutes. LPN #7 was asked what was the concern of not cleaning and disinfecting the glucometer for the allotted contact time per the manufacturers guidelines for the Assure Prism Glucometer. LPN #7 replied, it could have germs on it and cause infection. 2) A review of a facility policy titled, Hand Hygiene, with a revised date of 01/31/2023 revealed: POLICY It is the policy . to consider hand hygiene the primary means to prevent the spread of infections. Procedure . 4. Employees must wash their hands for at least (20) seconds using antimicrobial or non-antimicrobial soap and water or Alcohol gel under the following conditions . c) . Before and after direct resident contact . e) Before and after entering isolation precaution settings . h) Before and after assisting a resident with personal care . RI #46 was admitted to the facility on [DATE] with diagnosis of Type II Diabetes Mellitus without complications. RI #57 was admitted to the facility 01/22/2024 with diagnosis of Encounter for other Orthopedic Aftercare. RI #46's February's 2024 physician orders revealed the resident had an order for Enhanced Barrier Precautions related to an Open Wound to the Left Lower Extremity. On 02/08/2024 at 3:58 PM, LPN #7 was observed as she entered RI #46's room. LPN #7 did not put on gown or gloves before entering the room. LPN #7 placed the pads back onto the rail of the bed of RI #46. LPN #7 walked across the room from RI #46's bed to RI #57's Broda Chair and then touched RI #57's hands. LPN #7 did not wash or sanitize her hands before touching RI #57's hands. On 02/09/2024 at 3:40 PM, an interview was conducted with LPN #7. LPN #7 was asked what PPE was required before entering RI #46's room. LPN # 7 replied, gloves and gowns. LPN #7 was asked, what type of precautions was RI #46 on. LPN #7 replied, Enhanced Barrier Precautions for wound to his/her leg which requires wound care. LPN #7 was asked did she have the required PPE on before entering RI #46's room and before assisting RI #46 with his/her blanket and side rail pads. LPN #7 replied, no. LPN #7 was asked should she have had gloves and a gown on while moving the blanket off of RI #46's face and placing the side rail pad back to his/her bed. LPN #7 replied, yes. LPN #7 was asked, could the linens she moved off RI #46's face have been contaminated. LPN #7 replied, yes. LPN #7 was asked why she had not put on the proper PPE before entering RI #46's room. LPN #7 replied she was nervous, and she did not have an excuse. LPN #7 was asked what was the concern of not having proper PPE on when entering the room of a resident who was on Enhanced Barrier Precautions. LPN #7 replied, germs could get on her uniform, and she could spread the germs from resident to resident and it could cause a new infection. LPN #7 was asked should she have washed or sanitized her hands between the residents. LPN #7 replied, yes. LPN #7 was asked when should she wash or sanitize her hands. LPN #7 replied, when performing any high contact resident activity. LPN #7 was asked what was the concern of not sanitizing her hands in between resident-to-resident contact. LPN #7 replied, spreading germs or infection. On 02/09/2024 at 4:20 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked, what PPE should staff wear when a resident is on Enhanced Barrier Precautions; when performing any procedure. The DON replied, gloves and gowns. The DON was asked why should staff have the proper PPE on before entering a room where a resident is on Enhanced Barrier Precautions. The DON replied, to protect themselves from getting an infection or spreading it to other residents. The DON was asked what was the concern of not putting on the proper PPE before entering the room of the resident who is on Enhanced Barrier Precautions. The DON replied getting an infection or spreading it to other residents. The DON was asked should the staff perform hand hygiene between resident to resident contact. The DON replied, yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of a section in the facility's Privacy Notice (admission Packet) titled, . RESIDENT'S RIGHTS AND INFORMATION ., and review of [NAME] and Perry's FUNDAMENTALS OF NURSING NINTH EDITION, the facility failed to ensure residents and/or their representatives had the opportunity to formulate an advance directive including providing a written description of the facility's policies to implement advance directive and applicable state law. This deficient practice affected RI #'s 7, 23, 31, 44, 52, 62, 63, 70, 77, 78, and 79, 11 of 18 residents reviewed for advance directives. Findings include: A review of the facility's Privacy Notice, with an effective date of 04/14/2003, contained the following information: . RESIDENT'S RIGHT AND INFORMATION . 13. Resident Rights . (a) Exercise of Rights . (8) The facility must comply with the requirements relating to maintaining written policies and procedures regarding advance directive. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law . [NAME] & (and) Perry's FUNDAMENTALS OF NURSING NINTH EDITION with a copyright date of 2017, Chapter 23, titled, Legal implications in Nursing Practice, page 305, revealed the following: . Advance Directive Advance Directive include living wills, health care proxies, and durable powers of attorney for healthcare . They are based on values of informed consent, patient autonomy over end-of-life decisions, truth telling, and control over they dying process . Living Wills. Living wills represent written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. With this document a patient is able to declare which medical procedures he or she wants or does not want when terminal ill or in a persistent vegetative state . Health Care Proxies or Durable Power of Attorney for Health Care. A health care proxy or durable power of attorney for health care . is a legal document that designates a person or people of one's choosing to make health care decisions when a patient is no longer able to make decisions on his or her behalf. This agent makes health care treatment decisions on the basis of the patient's wishes . RI #7 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease and Occlusion and Stenosis of Unspecified Carotid Artery. RI #7 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 04/15/2022 in his/her medical records. Full Code was written on the bottom of the form, but there was no evidence in RI #7's medical record RI #7 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #23 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Cerebrovascular Disease Unspecified Atrial Fibrillation. RI #23 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 02/05/2016 in his/her medical records. DNR (Do Not Resuscitate) was written on the bottom of the form, but there was no evidence in RI #23's medical record RI #23 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #31 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Angina Pectoris and Acute Diastolic (Congestive) Heart Failure. RI #31 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 12/14/2023 in his/her medical records. Full Code was written and circled at the bottom of the form, but there was no evidence in RI #31's medical record RI #31 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #44 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Alzheimer's Disease and Chronic Combined Systolic and Diastolic Heart Failure. RI #44 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 03/08/2018 in his/her medical records. Full Code was written on the bottom of the form, but there was no evidence in RI #44's medical record RI #44 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #52 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Cerebrovascular Disease and Hypertensive Heart Disease with Heart Failure. RI #52 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 07/30/2021 in his/her medical records. Full Code was written on the bottom of the form, but there was no evidence in RI #52's medical record RI #52 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #62 was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbances. RI #62 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 11/15/2023 in his/her medical records. Pick one * Full Code (circled) or DNR was written on the bottom of the form, but there was no evidence in RI #62's medical record RI #62 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #63 was admitted to the facility on [DATE] with a diagnosis of Chronic Kidney Disease, Stage 3 and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. RI #63 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 11/15/2023 in his/her medical records. Written in on the bottom of the form was Pick one Full Code or DNR, neither circled, and there was no evidence in RI #63's medical record RI #63 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #70 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease and Unspecified Dementia. RI #70 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 10/25/2023 in his/her medical records. Written in on the bottom of the form was Pick one * Full Code or DNR, neither circled, and there was no evidence in RI #70's medical record RI #70 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #77 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease and Cerebellar Stroke Syndrome. RI #77 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 11/08/2023 in his/her medical records. Written on the bottom of the form was Full Code (circled) or DNR, but there was no evidence in RI #77's medical record RI #77 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #78 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Nontraumatic Intracerebral Hemorrhage and Alcoholic Cirrhosis of Liver with Ascites. RI #78 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 10/10/2023 in his/her medical records. Written on the bottom of the form was Pick one * Full Code or DNR, neither circled, and there was no evidence in RI #78's medical record RI #78 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. RI #79 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure. RI #79 had an ACKNOWLEDGEMENT OF ADVANCED DIRECTIVES form dated 12/06/2023 in his/her medical records. Written in on the bottom of the form was Full Code (circled) or DNR, but there was no evidence in RI #79's medical record RI #79 had been given the opportunity to formulate an advance directive concerning his/her medical care or end of life decisions. During an interview with the Social Service Director (SSD) on 02/09/2024 at 11:49 AM, the SSD was asked how she was involved with the advance directives. SSD stated she looked at the advance directive, and life sustaining measures should be included in the advance directive, but that was a part of the admission process, which was handled by the Assistant Administrator (AADM). During an interview with the AADM on 02/09/2024 at 12:04 PM, the AADM stated she provided residents with information for advance directives on admission by talking with the resident/family about the consent and explaining full code or DNR. The AADM said if the resident/family wanted to be DNR, she had them to sign, then the doctor signed and then the order was placed in the chart. The AADM said an advance directive was a full code where everything was done. When asked if she gave the residents an opportunity to formulate an advance directive, the AADM said no, that was the SSD responsibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, review of the facility's SMOKING CONSENT AND WAIVER, and review of a facility policy titled Resident Smoking, the facility failed to ensure: 1) smoking assessments were completed on Resident Identifier (RI) #'s 33, 35, 48, 56, 58, 65, 72 and 138 to assess the resident's ability to smoke safely, 2) the smoking materials were kept locked up on the weekend; and 3) RI #31's fall risk preventions were implemented. These deficient practices affected eight of eight residents who smoked at the facility; and RI #31, one of one resident sampled for falls. Findings include: 1) Review of the facility's undated SMOKING CONSENT AND WAIVER, revealed the following: . 4. I agree that . may assess my ability to safely continue to smoke as necessary based on my medical condition and/or the advice of my attending physician. This assessment includes but is not limited to my medical diagnosis, psychiatric diagnosis, physical impairments, fall and us (use) of psychotropic or pain medication . RI #33 was admitted to the facility on [DATE] with a diagnosis of Heart Failure, Unspecified. RI #33's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/02/2023, revealed RI #33's Brief Interview for Mental Status (BIMS) was six of 15 which indicated he/she had severely impaired cognitively, and RI #33 was coded as a current tobacco user under Section J. RI #35 was admitted to the facility on [DATE] with a a diagnosis of Hypertensive Heart and Chronic Kidney without Heart Failure, with Stage 1-4/Unspecified Chronic Kidney. RI #35's care plan, with a start date of 02/08/2024, revealed: Resident is a occasional smoker at facility . RI #48 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease Unspecified. A review of RI #48's admission MDS assessment, with an ARD of 09/14/2023, coded the resident as a current tobacco user under Section J. RI #56 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease with Late Onset. A review of RI #56's Annual MDS assessment, with an ARD date of 08/03/2022, coded the resident as a current tobacco user under Section J. RI #58 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease Unspecified. A review of RI #58's Annual MDS assessment, with an ARD date of 02/05/2024, revealed RI #58 was coded as a current tobacco user under Section J. RI #65 was admitted to the facility on [DATE] with a diagnosis of Nicotine Dependence and Hemiplegia follow Unspecific Cerebrovacular Disease affecting Left Nondominant Side. A review of the admission MDS assessment, with an ARD date of 08/15/2023, revealed RI #65 started smoking after the admission assessment was completed. RI #72 was admitted to the facility on [DATE] with a diagnosis of Tobacco Use and Nicotine Dependence. A review of the admission MDS assessment, with an ARD date of 10/18/2023, revealed RI #72 was coded as a current tobacco user. RI #138 was admitted to the facility on [DATE] with a diagnosis Chronic Obstructive Pulmonary Disease. A review of the admission MDS assessment, with an ARD date of 02/06/2024, revealed RI #138 was coded as a current tobacco user. On 02/08/2024 at 11:47 AM, during an interview with the Activity Director (AD), the AD said the nurses assessed the residents for smoking. The AD said the she provided supervision for residents while smoking, but had not been trained. She said she just watched them. On 02/08/2024 at 11:55 AM, during an interview with the Registered Nurse (RN) Supervisor, she said she did not know who assessed the residents for smoking but it was not her. The RN Supervisor said the risk of not assessing a resident for their ability to smoke was that the resident could harm themselves. When asked when should residents be assessed for their ability to smoke, the RN Supervisor said at least once a month. On 02/08/2024, the surveyor received from the Director of Nursing (DON) a statement which documented: . Smoking assessments are not done for residents . 2) A review of a facility policy titled Resident Smoking, with a revised date of 01/31/2023, revealed the following: . POLICY . All tobacco products will be kept by the activity department . PROCEDURE . 3. The Activities staff will lock the smoking materials up for safe keeping . 6. Violation of the policy puts resident's safety in danger . On 02/08/2024 at 11:47 AM, during an interview with the AD, she said she had a plastic box with snaps on it that she keeps the resident's cigarettes in. The AD said the box is locked in a cabinet in her office. The AD said she was the only one with a key to the locked cabinet. The AD said she leaves the box of cigarettes in a file cabinet in the RN's office on Fridays. The AD said she did not know if there was a key to the filing cabinet or not. On 02/08/2024 at 2:00 PM, during an interview with the RN Supervisor, when asked where she got the cigarette box from, she said in the RN's office in a filing cabinet. The RN supervisor said the filing cabinet was not locked and the plastic box that the cigarettes were in was not locked either. The RN Supervisor said she did not know why, when the cigarettes were in the RN's office, they were not locked up. The RN Supervisor said the risk of not locking smoking paraphernalia up was someone could take the cigarettes. When asked where the cigarettes should be kept, she said in the AD office locked up. 2) RI #31 was was admitted to facility on 11/29/2023 and readmitted on [DATE], with diagnoses to include Muscle Weakness, Unsteadiness on Feet, Other Lack of Coordination, Repeated Falls, and History of Falling. RI #31's Potential for fall related to decreased mobility, decreased ADL (Activities of Daily Living) functioning, history of falls care plan, with a start date of 11/29/2023, revealed the following interventions: . 4. Place on falling star program to alert staff of potential for falls . 7. Chair pad alarm applied to chair to alert staff of unassisted transfers . Bed alarm while in bed . RI #31's admission MDS assessment, with an ARD of 12/06/2023, revealed RI #31 BIMS score was two of 15, which indicated severely impaired cognition. The MDS also indicated RI #31 had fallen two or more times, and used the chair alarm daily during this assessment period. Review of an UNUSUAL OCCURRENCE RECORD dated 12/19/2023, revealed RI #31 was found sitting on the bathroom floor with no apparent injuries, the care plan was reviewed; and a bed alarm was added. RI #31's most recent Physician Orders for February 2024 revealed the following: . Bed Pad Alarm Order: Bed pad alarm applied to bed to alert staff of unassisted transfers . Chair Pad Alarm Order: Chair pad alarm applied to chair to alert staff of unassisted transfer . Resident placed on the Falling Star Program due to increased fall risk: . Yellow bracelet applied to upper extremity to ID (identify) resident is at risk for falls and alert staff . On 02/08/2024 at 8:44 AM, RI #31 was observed sitting in the hallway in his/her wheelchair (WC). No chair alarm was observed on the WC at this time. Also, no yellow bracelet was observed to either of RI #31's wrist. The surveyor entered RI #31's room and an alarm monitor box was observed on top of RI #31's dresser drawer. On 02/08/2024 at 3:10 PM, RI #31 was observed sitting in his/her WC in his/her room. No alarm was observed on the WC and the alarm monitor box remained on top of dresser drawer in RI #31's room. On 02/08/2024 at 6:46 PM, RI #31 remained in his/her WC. Again, no alarm was observed on the WC. On 02/09/2024 at 8:11 AM, RI #31 was observed in bed in his/her room. RI #31's WC was observed in the room with no alarm device on the WC. The alarm monitor box remained on top of RI #31's dresser drawer in the room. On 02/09/2024 at 8:15 AM, the surveyor conducted an interview with Certified Nursing Assistant (CNA) #13. CNA #13 said she thought RI #31 was a fall risk. CNA #13 said RI #31's fall risk interventions were the bed and chair alarm and RI #31 should have been wearing a yellow bracelet. CNA #13 said she did not see the yellow bracket on RI #31's wrist. CNA #13 said when RI #31 was up in the WC there should have been a chair alarm on the WC but she did not see a chair alarm on RI #31's WC. When asked did she see a bed alarm on RI #31's bed, CNA #13 said no. CNA #13 said the alarm on RI #31's dresser was for RI #31's bed. CNA #13 said the alarm was not connected. When asked what was there a potential for when RI #31's fall interventions were not in place, CNA #13 said RI #31 falling. On 02/09/2024 at 12:12 PM, an interview was conducted with the Registered Nurse (RN) Unit Manager. The RN Unit Manager said RI #31 was a fall risk. The RN Unit Manager said RI #31 would be easily identified as a fall risk by his/her yellow fall risk wrist band. The RN Unit Manager said RI #31 was care planned for a bed and chair alarm. When asked why it would be important to ensure fall risk interventions were being implemented, the RN Unit Manager said to prevent falls/injury.

Based on observation, interviews, review of an undated facility policy titled, DIETARY POLICY SANITATION AND INFECTION CONTROL, and review of the 2022 Food Code from the United States (U.S.) Food and Drug Administration (FDA); the facility failed to ensure two pans of casserole in the freezer was labeled with a use by date. This was observed on 02/05/2024, and had the potential to affect 84 out of 88 residents who were receiving food from the facility's kitchen. Findings include: A review of an undated facility policy titled, DIETARY POLICY SANITATION AND INFECTION CONTROL revealed the following: . 10. Storage of Leftovers . b. Leftovers, cold foods etc., shall be kept on a tray and covered with a fitted lid, foil wrap or plastic wrap. Each tray or container shall be dated . Review of the 2022 U.S. Food and Drug Administration Food Code revealed the following: . 3-501.17 Ready-to- Eat, Time/Temperature Control for Safety Food, Date Marking . (A) . refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES . On 02/05/2024 at 1:59 PM during the initial kitchen tour with the Dietary Manager (DM), two large casseroles were observed covered with no use by date label on the casseroles. When the DM was asked why the casseroles were not dated, she stated she was not sure why, and that it must have been missed. The DM was asked what was the importance of dating and labeling food items, she stated to make sure the items were safe to eat. On 02/07/2024 at 5:08 PM the Registered Dietician (RD) was interviewed by telephone. When asked, when were food items supposed to be labeled and dated, the RD stated the day upon receiving, the day upon preparing and the day upon opening. When asked what was the importance of the use by date the RD stated to ensure patient safety and that food did not spoil. The surveyor shared with the RD that during the initial kitchen tour two casseroles in the freezer were not dated. When asked should the items have been dated, the RD stated yes. When asked what would be the potential concern with undated food, the RD stated the food may be spoiled and placed residents at risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of a facility policy titled, INFECTION CONTROL PREVENTING THE SPREAD OF INFECTION, the facility failed to ensure: 1. the nurse did not lay the tip of a tube feeding line on a resident's blanket then re-attach it to the Gastrostomy Tube (G-Tube) and 2. the nurse did not lay the plunger of the syringe on the bed and return it to a bag that contained the clean barrel of the syringe. These deficient practices affected Resident Identifier (RI) #4, one of six residents observed during the medication pass observation. Findings Include: Review of a facility policy titled, INFECTION CONTROL PREVENTING THE SPREAD OF INFECTION with an effective date of 4/20/19, revealed, . POLICY It is the policy of (name of the facility) to have knowledge regarding the factors associated with the spread of infection in the facility. PROCEDURE 1. Many factors contribute to a substantial severity and frequency of infections and infectious diseases in nursing homes. These infections can arise from individual or institutional factors, or both. Modes of transmission of infection include but are not limited to: *Contact . 3. Institutional factors - In addition to individual factors, institutional factors may also facilitate transmission of infections among residents, including but not limited to: . *Direct/indirect contact with equipment used to provide care; . RI #4 was admitted to the facility on [DATE]. Diagnoses to include Hemiplegia, Seizure disorder and Cerebrovascular Disease. A review of the Quarterly Minimum Data Set (MDS) assessment, assessment reference date 7/22/19, revealed RI #4's Brief Interview for Mental Status score was 6 out of a possible 15. This score indicated RI #4 was severely impaired for daily decision making skills. A review of RI #4's Medication Administration Record (MAR) indicated the resident's medication was provided via G-Tube. An observation was made on 7/31/19 at 12:04 PM, of a medication pass performed by Employee Identifier (EI) #4, a Licensed Practical Nurse, to RI #4. After preparing the medication, EI #4 disconnected the fluid tubing from the G-Tube and laid the tip of the fluid line on the covers that laid across the resident's lower abdomen. EI #4 checked for residual in the G-Tube, then she separated the syringe. EI #4 laid the inner plunger on the covers over the resident's lower abdomen. EI #4 administered the medications, then reattached the fluid line tubing tip that had been lying on the covers, to the G-Tube. EI #4 washed and dried the barrel of the syringe, placed the contaminated plunger back into the barrel and put the syringe in the bag for storage. An interview was conducted on 7/31/19 at 3:28 PM, with EI #4. EI #4 was asked when she administered medicines via Gastrostomy Tube for RI #4, where she placed the tip of the tubing once she detached it from the G-Tube. EI #4 answered she laid it on the resident's blanket. EI #4 was asked where she laid the plunger to the syringe while she was using the barrel to administer the medications. EI #4 answered she laid it by the bag on the blanket. EI #4 was asked what she did with the tip of the tubing once she had finished with medication administration. EI #4 answered she re-connected it to the tubing. EI #4 was asked what she did with the plunger to the syringe once she washed and dried the barrel. EI #4 answered she put it back in the bag for storage. EI #4 was asked what was the concern with laying the tip of the tubing on a resident's blanket and then re-attaching it to the resident's G-Tube. EI #4 answered infection control. EI #4 was asked what was the concern of placing a contaminated plunger into a clean bag with syringe barrel and returning it to the storage bag to be used again. EI #4 answered infection control. EI #4 was asked what was the facility policy regarding cross contamination. EI #4 answered to prevent infection by keeping a clean area and not to cross contaminate. EI #4 was asked what should have been done with the tip of the tubing when she disconnected it from the G-Tube. EI #4 answered it should have been capped and hung across the tube feeding pole. An interview was conducted on 8/01/19 at 10:24 AM with EI #3, the Assistant Director of Nursing/Infection Control Nurse. EI #3 was asked to please explain the process for using the G-Tube for medication administration. EI #3 answered the nurse should disconnect the tubing (adding there should be a cap to place over the tip) then cap the tubing. EI #3 said the nurse should have a 60 cc syringe and plunger. Next the nurse should check for residual, then remove the plunger. The nurse should give 30 cc's (cubic centimeters) of water flush, then a medication, and give a 30 cc flush afterwards. EI #3 stated the nurse would remove the syringe, uncap the tubing line and place it back into the tube. EI #3 stated the nurse would then take the syringe and plunger to the sink to wash and dry them, then place them back into the bag for storage. EI #3 was asked where the plunger should be when it was not in use. EI #3 answered in the bag. EI #3 was asked what was the concern with the line being uncapped and laid on a resident's blanket. EI #3 answered it was an infection control issue because there was no cap to act as a barrier on the tip that would be re-introduced to the G-Tube. EI #3 was asked what was the concern of laying the plunger on the blanket and not washing it prior to placing it back in the bag with the clean barrel. EI #3 answered it was an infection control issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, the facility failed to ensure licensed staff did not place Resident Identifier (RI) # 53's nebulizer mask in a bag, while still wet with moisture after a treatment was administered. This was observed on 6/25/18 and affected one of one resident observed for nebulizer treatments and one of four nurses observed during medication administration. Findings Include: A review of of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, Chapter 29, Infection Prevention and Control, page 455, documented: .Cleaning. Cleaning is the removal of organic material .from objects and surfaces .When an object comes in contact with an infectious or potentially infectious material, it is contaminated .Reusable objects need to be cleaned thoroughly before reuse . RI # 53 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, unspecified. A review of RI # 53's Physician's Orders dated 6/01/18 - 6/30/18 documented: .ALBUTEROL SUL (solution) 2.5 MG(milligrams)/3 ML(milliters) .INHALE 1 VIAL (3ML) PER NEBULIZER EVERY FOUR HOURS . A review of RI # 53's Medication Administration Record (MAR) documented he/she was given Albuterol 2.5 MG/3 ML on 6/25/18 at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. On 6/25/18 at 9:10 a.m., during medication administration observation, the surveyor observed staff administer RI # 53's medication to include Albuterol 2.5 MG/3 ML. At 9:26 a.m. Employee Identfier (EI) # 1, Licensed Practical Nurse (LPN), took RI # 53's nebulizer face mask off and placed it in a plastic bag. The surveyor observed moisture on the face mask inside the plastic bag. EI # 1 did not wipe or clean the face mask prior to putting it in the plastic bag. On 6/25/18 at 5:08 p.m. an interview was completed with EI # 1. EI #1 was asked should you wipe off or clean the face mask after a nebulizer treatment, if the mask has moisture on the face mask, prior to putting it back in the plastic bag. EI # 1 replied yes. EI # 1 was asked if there was wet moisture on RI # 53's face mask when it was placed in the plastic bag. EI # 1 stated yes. RI # 53 further stated she did not clean the mask prior to placing it in the bag after RI # 53's treatment was completed. EI # 1 stated not cleaning and drying the mask could cause a respiratory infection or bacteria growth. On 6/25/18 at 5:34 p.m. an interview was completed with EI # 2, Director of Nursing, Infection Preventionist. EI # 2 was asked what would usually be done after a nebulizer treatment was completed. EI # 2 replied staff would wipe it off and place it in a plastic bag. EI # 2 stated the mask should not be placed in the plastic bag with moisture on it. EI # 1 was asked what affect this would have on the resident. EI # 2 stated it could cause an infection.