**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide information regarding a resident's right to develop an Advance Directive for 2 of 11 sampled residents (Resident #49 and #302) reviewed for Advance Directives. The findings include: Review of the facility's policy titled, Advance Directives, dated 12/2016, revealed .Advance directives will be respected in accordance with state law and facility policy .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment to formulate an advance directive if he or she chooses to do so . Review of the medical record, revealed Resident #49 was admitted to the facility on [DATE] with diagnoses of Spinal Stenosis, Diabetes Mellitus, Anemia, and Adjustment Disorder with Anxiety. Review of the 5-day Minimum Data Set (MDS) dated [DATE], revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Review of Resident #49's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed or provided written information regarding her right to develop an Advance Directive upon admission. Review of the medical record, revealed Resident #302 was admitted to the facility on [DATE], with diagnoses of Displaced Spiral Fracture Right Tibia, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Hypertension, and Urinary Tract Infection. Review of admission MDS dated [DATE], revealed Resident #302 had a BIMS of 15, which indicated she was cognitively intact. Review of Resident #302's medical record, revealed there was no Advance Directive present and there was no documentation the resident or her legal representative was informed or provided written information regarding her right to develop an Advance Directive upon admission. During an interview on 4/19/2022 at 3:28 PM, the Assistant Director of Nursing (ADON) confirmed that Resident #49 and #302 did not have Advance Directives and there was no documentation the residents or legal representatives were informed or provided written information regarding their right to develop an Advance Directive upon admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to accurately assess a pressure injury for 1 of 1 sampled resident (Resident #205) reviewed for pressure ulcers. The findings include: Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, dated 4/2018, revealed .the nurse shall describe and document/report the following .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate . Review of the closed medical record, revealed Resident #205 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Hypertensive Chronic Kidney Disease, Pressure Ulcer of the Right Hip, Diabetes Mellitus, Anemia, Osteoarthritis, Acute Kidney Failure, and Hypertension. Review of the Clinical Note Entry dated 3/3/2022, revealed Resident #205 had a Stage 2 pressure injury on the coccyx that was present on admission to the facility. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #205 had a Stage 2 pressure injury that was present on admission to the facility. Review of the Clinical Notes Report dated 3/15/2022, revealed .PI [Pressure Injury] to coccyx, stage II [2] .7cm [centimeter] x [by] 7.2cm x 0.2cm, 80% [percent] tan slough [necrotic tissue] to wound bed . Review of the Clinical Notes Report dated 3/22/2022, revealed .PI [Pressure Injury] to coccyx, stage II [2] .8cm x 9.5cm x UTD [unable to determine] [depth], 100% dark brown to yellow, firm adherent tissue to wound bed . During an interview on 4/20/2022 at 1:50 PM, the Director of Nursing (DON), confirmed that Resident #205 had a stage 2 pressure injury to the coccyx that was present on admission to the facility. The DON confirmed that Resident #205's coccyx pressure injury should have been re-classified as a stage 3 on 3/15/2022, when there was 80% slough present, and as an unstageable on 3/22/2022, when the wound depth was unable to be determined due to being 100% covered with a firm adherent tissue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to maintain privacy and confidentiality of medical records for 1 of 5 (Resident #119) sampled residents. The findings include: The facility's undated HIPAA [Health Insurance Portability and Accountability Act]/PRIVACY SAFEGUARDING AND STORING PROTECTED HEALTH INFORMATION policy documented, .The policy of this Community is to ensure, to the extent possible, that PHI [Private Health Information] is not intentionally or unintentionally .disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulation governing confidentiality and privacy of health information .Access to computer-based PHI shall be limited to staff members who need the information for treatment, payment, or health care operations .Community staff members shall log off their workstation when leaving the work area .Computer monitors shall be positioned so that unauthorized persons cannot easily view information on the screen . Medical record review revealed Resident #119 was admitted to the facility on [DATE] with diagnoses of Trigeminal Neuralgia, Urinary Tract Infection, Hypertension, Cognitive Communication Deficit, Macular Degeneration, Hyperlipidemia, Gastro-esophageal Reflux Disease, Diabetes, Depression, and Mood Disorder. Observations in the Sunflower Hall on 1/29/19 at 8:10 AM, revealed Resident #119's personal health information opened and visible on the computer monitor on the unattended medication cart. Interview with RN #2 on 1/29/19 at 8:15 AM, at the medication cart in the Sunflower Hall, RN #2 was asked if a resident's personal health information should be visible on the computer monitor when the medication cart was unattended. RN #2 stated, No. Interview with the Interim Director of Nursing (DON) on 1/29/19 at 11:10 AM, in the Conference Room, the Interim DON was asked if a resident's personal health information should be visible on the computer monitor when the medication cart was unattended. The DON stated, No ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure medications were available for administration for 1 of 4 (Resident #269) residents observed during medication pass. The findings include: The facility's Medication Administration Schedule policy revised April 2007documented, .Medications shall be administered according to established procedures . Medical record review revealed Resident #269 was admitted to the facility on [DATE] with diagnoses of Aftercare Following Joint Replacement Surgery, Fracture of the Neck of the Right Femur, Diabetes, Disorder of Kidney and Ureter, Vitamin Deficiency, and Malignant Neoplasm of the Stomach. The Physician Order Sheet dated January 2019 documented, .ergocalciferol (vitamin D2) 2,000 unit tablet .every one day starting 1/19/2019 . Observations on 1/29/19 at 8:50 AM, at the med cart on Sunflower Hall, revealed Registered Nurse (RN) #2 was unable to administer ergocalciferol to Resident #269 because the medication was not available. Review of the January 2019 Medication Administration Record (MAR) revealed ergocalciferol was not administered on 1/26/19,1/27/19 and 1/29/19 because the medication was not available. Interview with the Interim Director of Nursing (DON) on 1/29/19 at 11:10 AM, in the Conference Room, the Interim DON was asked if it was acceptable not to give a medication for 2-3 days because it is not available. The DON stated, No ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH EDITION provided by the American Society of Consultant Pharmacists, policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of a significant medication error when 1 of 4 (Registered Nurse (RN) #1) nurses failed to administer food promptly after a rapid-acting insulin injection. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS .NovoLog .Insulin Aspart .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION .5-10 minutes prior to meals . 2. The facility's Insulin Administration policy revised on 9/2014, documented, .1. The three key characteristics of insulin are: a. Onset of action-how quickly the insulin reaches the bloodstream and begins to lower blood glucose .Rapid-acting .Onset .10-15 min [minutes] . 3. Medical record review revealed Resident #169 was admitted to the facility on [DATE] with diagnoses of Compression Fracture of the Lumbar Vertebrae, Malignant Neoplasm of the Prostate, Diabetes, and Hypertension. The Physician Order Sheet dated January 2019 documented, .NovoLOG Flexpen U [Unit] .100 unit/mL [milliliter] subcutaneous (SSI) [Sliding Scale Insulin] INSULIN PEN .Therapeutic Range Sliding Scale Insulin .Blood sugar is 141.00-200.00 8 Units . Observations in Resident #169's room on 1/28/19 at 4:45 PM, revealed RN #1 obtained a blood glucose test from Resident #169 with a reading of 172. Observations in Resident #169's room on 1/28/19 at 4:57 PM, revealed RN #1 administered Novolog 8 units to Resident #169. Observations in Resident #169's room on 1/28/19 at 5:45 PM, revealed Resident #169 was delivered a meal tray. Staff failed to provide a meal or substantial snack for 48 minutes after Novolog a rapid-acting insulin was administered. Interview with the Interim Director of Nursing (DON) on 1/29/19 at 11:10 AM, in the Conference Room, the Interim DON was asked how soon should a resident eat after receiving a Novolog injection. The Interim DON stated, With short acting, 15-30 minutes.

Based on policy review, observation, and interview, the facility failed to ensure medications were securely locked and inaccessible to residents, unauthorized staff and visitors in 1 of 4 medication (Sunflower Medication Cart) storage areas. The findings include: Review of the facility's undated Storage of Medications policy revealed, .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use or out of sight, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . Observations in the Sunflower Hall on 1/29/19 at 8:10 AM, revealed a medication cart unlocked and unattended. The medication cart contained numerous containers of physician prescribed medications. Interview with Registered Nurse (RN) #2 on 1/29/19 at 8:15 AM, at the Sunflower Medication Cart, RN #2 was asked if the medication cart should be unlocked and unattended. RN #2 stated, No. Interview with the Interim Director of Nursing (DON) on 1/29/19 at 11:10 AM, in the Conference Room, the Interim DON was asked if a medication cart should be locked when unattended. The Interim DON stated, Yes, if it is out of sight, it should be locked.