**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to accurately address an advanced directive for 1 (Resident #16) of 24 residents reviewed. The findings include: 1. Review of the undated facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives .Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State Law .relating to the provision of health care when the individual is incapacitated .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .The facility will provide the resident or resident representative information .about the right to refuse medical or surgical treatment and formulate an advance directive .During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any change related to any advance directives .Decisions regarding the advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process .Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . Review of the undated facility policy titled, Cardiopulmonary Resuscitation (CPR), revealed It is the policy of this facility to adhere to residents' rights to formulate advance directives .If a resident experiences a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and .In accordance with the resident's advance directives .In the absence of advance directives or a Do Not Resuscitate order .Staff will maintain current CPR certification for healthcare providers through a CPR provider whose training . 1. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses which included Hypertensive Heart (High Blood Pressure changes in the Heart) and Chronic Kidney disease with Heart Failure and Stage 1 through Stage 4 Chronic Kidney Disease, or Unspecified chronic Kidney Disease, Permanent Atrial Fibrillation (irregular heart beat), Chronic Systolic (Congestive) Heart Failure, and Essential (Primary) Hypertension (High Blood Pressure). Review of the facility form titled, Physician Orders for Scope of Treatment (POST), dated [DATE], revealed Resident #16 elected CPR, resuscitate, limited additional Intervention, no artificial nutrition by tube. Review of the physician orders for Resident #16 order dated [DATE] revealed an order to admit to [Named] hospice. Review of the facility form titled, Physician Orders for Scope of Treatment (POST), dated [DATE], revealed Resident #16 elected Do Not Resuscitate (DNR), limited additional intervention, and defined trial period of artificial nutrition by tube. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitively impairment, and on Hospice while a Resident. Review of the Care Plan dated [DATE], for Resident #16 revealed a focus on hospice with no intervention for advance directives. The facility failed to focus on Advance Directives or CPR code status. Review of the POST form dated [DATE], revealed cardiopulmonary resuscitation (CPR), resuscitate, limited additional intervention, no artificial nutrition by tube. Review of Resident #16's hospice chart revealed a POST form dated [DATE], Cardiopulmonary Resuscitation Do Not Attempt Resuscitation with limited additional interventions, and defined trial of artificial nutrition by tube. During an interview on [DATE] at12:30, Registered Nurse (RN) D confirmed Resident #16's paper chart contained a POST form stating resuscitate and the hospice chart contained a POST form stating do not attempt resuscitation. During an interview on [DATE] at 7:50 PM, the Director of Nursing (DON) confirmed the discrepancy of Resident #16's code status in the hospice record and the facility chart. The DON was asked if the POST form in the hospice record and the facility record should be the same. The DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to obtain a physician's orders related to skin care treatments for 1 of 3 (Resident #33) residents reviewed for skin conditions. The findings include: Review of the undated facility policy titled, Wound Treatment Management, revealed .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .Treatments will be documented on the Treatment Administration Record . Review of the undated facility policy titled, Physician Orders/Verbal Orders, revealed, .Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so .Repeat any prescribed orders back to the physician .Enter the order into the medical record . Review of the undated facility policy titled, Documentation of Wound Treatments, revealed .Wound assessments are documented upon admission, weekly, and as needed .Type of wound .Measurements .Description of wound characteristics .Wound treatments are documented at the time of each treatment . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Orthopedic Aftercare, Repeated Falls, and Acute Kidney Failure. Review of the facility form titled, admit/readmit screener, dated 2/28/2025, revealed .skin integrity .Right elbow .skin tear . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #33 was cognitively intact. Review of the care plan dated 3/6/2025, revealed there were no interventions to address the skin tear to the right elbow. Review of the Nurses Note dated 3/6/2025 at 3:25 PM, recorded as a late entry and documented on 3/10/2025 at 3:26 PM, revealed .STI [Skin Tear Injury] to Rt [Right] elbow noted on admit [admission] has not required tx [treatment] and is scabbed . Review of the physician's order for Resident #33 dated 3/2025, revealed the physician's order failed to address the skin conditions to the right elbow. Review of the facility form titled, Non-Pressure Skin Report, dated 3/8/2025, 3/14/2025m and 3/22/2025, failed to address skin conditions to Resident #33's right elbow. During an observation and interview in the Resident's room on 3/25/2025 at 8:51 AM, revealed a border gauze to Resident #33's right elbow region. Resident #33 stated, .have a spot on my arm .they put a bandage on it, I asked for one because it bleeds .groin is sore .they will apply cream if I ask . Observation in the Resident's room on 3/26/2025 at 8:24 AM, revealed Resident #33's right arm was exposed with a border gauze pulled up and attached on one side with slight blood-tinged area. A small opened area with no scab was observed to the right elbow region. During an interview on 3/26/2025 at 10:51 AM, Licensed Practical Nurse (LPN) E was asked if Resident #33 had a skin condition to her right arm. LPN E stated .she had a place on her right elbow, but I haven't heard anything about it recently . LPN E was asked if Resident #33 had complained of irritation in her groin, LPN E confirmed that they put protective barrier cream to her groin and that the area had been monitored. LPN E confirmed there was no treatment order for Resident #33's right elbow or groin. During an interview on 3/27/2025 at 7:50 PM, the Director of Nursing (DON) was asked if a resident required barrier cream application or had an open area that required a bandage should there be a physician's order for that care. The DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to provide a safe, sanitary, and homelike environment for 6 of 32 (Resident #8, 11, 14, 25, 27, 31, 33, 48, 51, 207) resident rooms observed. The finding include: 1. Review of the facility policy titled, Storage of Bedpans and Urinals, dated 2024, revealed .Bedpans and urinals are for single resident use only. [NAME] with the resident's name and discard upon discharge. Store bedpans and urinals in the resident's bathroom after placing in a plastic bag or as per facility policy . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Pseudobulbar Affect, Hypertensive Heart Disease with Heart Failure, Peripheral Vascular Disease, and Unspecified Dementia, unspecified severity with Psychotic Disturbance. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #8 was cognitively intact. Observation in the bathroom of Resident #8 on 3/24/2025 at 12:10 PM, 3/25/2025 at 10:40 AM, and 3/26/2025 at 8:33 AM, revealed a yellow bedpan located between the grab bar and wall behind the toilet was unlabeled and unbagged. 3. Resident #11 and #14 were roommates. a. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Epilepsy, Need for assistance with personal care, and Essential Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #11 was cognitively intact. b. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Dysarthria, and Cerebral Infarction. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #14 was cognitively intact. c. Observation in the shared bathroom of Resident #11 and Resident #14 on 3/24/2025 at 12:04 PM and 1:07 PM, revealed a bed pan located between the grab bar and the wall behind the toilet was unlabeled and unbagged. During an observation and interview in Resident #11 and Resident #14's bathroom on 3/26/2024 at 8:55 AM, RN IP/Unit Manager confirmed the bedpan should be labeled and bagged. 4. Resident #25 and #27 were roommates. a. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Chronic Diastolic Heart Failure, Atherosclerotic Heart Disease and Bipolar Disorder. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #25 was severely cognitively impaired. b. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety Disorder and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #27 was moderately cognitively impaired. c. Observation in the shared bathroom of Resident #25 and Resident #27 on 3/24/2025 at 11:40 AM, 3/25/2025 at 9:05 AM, and 3/26/2026 at 8:22 AM, revealed the bedpan labeled for Resident #27 was unbagged. 5. Resident #31 and #33 were roommates. a. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE], with diagnoses including Acute Cystitis, Fracture of Left Humerus, Dislocation of Right Shoulder, and Dementia. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #31 was moderately cognitively impaired. b. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Orthopedic Aftercare, Repeated Falls, and Acute Kidney Failure. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #33 was cognitively intact. c. Observation in the shared bathroom of Resident #31 and Resident #33 on 3/25/2025 at 8:59 AM and 3:33 PM, and 3/26/2025 at 8:24 AM, revealed an unlabeled and unbagged bedpan lying on top of the shower chair. 6. Resident #48 and #51 were roommates. a. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Severe Protein-Calorie Malnutrition, and Mood disturbance, and Alzheimer's Disease. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated Resident #48 was severely cognitively impaired. b. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses including Cellulitis of Right Lower Limb, Cellulitis of Left Lower Limb, Acute Kidney Failure, Repeated Falls, and Type II Diabetes Mellitus. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #51 was cognitively intact. c. Observation in the shared bathroom of Resident #48 and Resident #51 on 3/24/2025 at 12:47 PM, 3/25/2025 at 10:42 AM, and 3/26/2025 at 8:28 AM, revealed a unlabeled and unbagged pink bedpan between the grab rail and wall behind the toilet. During an observation and interview in the shared bathroom of Resident #48 and Resident #51 on 03/26/25 at 8:58 AM, the RN/IP Unit Manager confirmed a pink bedpan located between the grab bar and wall behind the toilet was unlabeled. 7. Review of the medical record revealed Resident #207 was admitted to the facility on [DATE] with diagnoses including Pneumonitis due to Inhalation of Food and Vomit, Sepsis, Chronic Obstructive Pulmonary Disease, Acute Kidney Failure, Cystitis, Dysphagia, and Hypertension. Review of medical records revealed Resident #207 was a new admission with no MDS assessment available. Observation in the bathroom of Resident #207 on 03/24/25 at 12:27 PM and 3/25/2025 at 10:37 AM, revealed a yellow bedpan and a pink bedpan located between the grab bar and the wall behind the toilet was unlabeled and unbagged. Observation and interview in the bathroom of Resident #207 on 3/26/2025 at 9:15 AM, revealed the RN/IP Unit Manager confirmed there was one yellow bedpan and one pink bedpan located between the grab bar and wall behind the toilet that was unlabeled. 8. During an interview on 03/26/25 at 8:47 AM, the RN/IP/Unit Manager confirmed bedpans and urinals should be stored in the resident's bathrooms, labeled with the resident's name, and stored after use, placing in a plastic bag. The RN/IP Unit Manager stated, If a bedpan doesn't have a name on it, it goes in the trash. The same for urinals, and/or denture cups. During an interview on 3/27/2025 at 7:50 PM, the Director of Nursing (DON) was asked should bed pans be labeled with the resident's name and stored in a plastic bag. The DON stated Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to implement a person-centered care plan to address the code status for 21 of 24 (Resident #2, #4, #5, #9, #11, #15, #16, #17, #19, #22, #25, #27, #29, #32, #33, #34, #45, #48, #51, #207 and #257) sampled residents and failed to implement a fall intervention for 1 (Resident #18) of 6 residents reviewed for accidents. The findings include: 1. Review of the undated facility policy titled, Comprehensive Care Plans, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing .needs .The comprehensive care plan will describe, at a minimum .The services that are to be furnished to attain or maintain the residen' s highest practicable physical, mental, and psychosocial well-being . Review of the undated facility policy titled, Residents' Rights Regarding Treatment and Advance Directives, revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate advance directives .Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State Law .relating to the provision of health care when the individual is incapacitated .During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any change related to any advance directives .Decisions regarding the advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process .Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . Review of the undated facility policy titled, Accidents and Supervision, revealed, .The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes .Implementing interventions to reduce hazard(s) and risk(s) . Review of the undated Frequent Flyer Program, revealed, As a way to alert staff of high risk patients that have fallen, we will adopt the following program .When a patient falls, they are identified by an airplane on the door. The plane will be placed on the outside of the patient's door . 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Anemia, and Dementia. Review of the facility form titled, Physician Orders for Scope of Treatment (POST), dated 9/17/2009, revealed Resident #2 elected Cardiopulmonary Resuscitation (CPR), full treatment, Antibiotics, IV fluids and feeding tube. Review of the Care Plan dated 1/8/2025, revealed the facility failed to include the CPR code status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderately impaired cognition. 3. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Cerebrovascular Disease, Thyrotoxicosis, Chronic Ischemic Heart Disease, and Dementia. Review of the POST form dated 7/27/2021, revealed Resident #4 elected Do Not Attempt Resuscitation (DNR), Comfort Measures, and no artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #4 was severely cognitively impaired. Review of the Care Plan for Resident #4 dated 3/10/2025, revealed the facility failed to include the CPR code status. 4. Review of the medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Humerus Fracture, Urinary Tract Infection, Dementia, Osteoporosis, and Congestive Heart Failure. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #5 was moderately cognitively impaired. Review of the POST form dated 2/21/2025, revealed Resident #5 elected CPR. Review of the Care Plan for Resident #5 dated 2/24/2025, revealed the facility failed to include the CPR code status. 5. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dysphagia, and Chronic Obstructive Pulmonary Disease. Review of the POST form dated 5/4/2021, revealed Resident #9 elected DNR, Comfort Measures, and no artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #9 was severely cognitively impaired. Review of the Care Plan dated 2/24/2025, revealed the facility failed to include the CPR code status. 6. Review of the medical record revealed Resident #11 admitted to the facility on [DATE], with diagnoses including Epilepsy, Need for assistance with personal care, and Hypertension. Review of the POST form dated 5/25/2022, revealed Resident #11 elected DNR, comfort measures, and no artificial nutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #11 was cognitively intact. Review of the Care Plan dated 3/17/2025, revealed the facility failed to include CPR code status. 7. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Osteoarthritis, Anxiety, Depression, and Insomnia. Review of the POST form dated 3/17/2025, revealed Resident #15 elected DNR. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #15 was cognitively intact. Review of the Care Plan dated 3/18/2025, revealed the facility failed to include the CPR code status. 8. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease, Atrial Fibrillation, Congestive Heart Failure, and Cardiac Arrhythmia. Review of the POST form dated 7/29/2024, revealed Resident #16 elected CPR, Resuscitate, Limited Additional Intervention, no artificial nutrition by tube. Review of the POST form dated 10/21/2024, revealed Resident #16 elected DNR, Limited Additional Intervention, and a Defined trial period of artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #16 was severely cognitively impaired. Review of the Care Plan dated 2/10/2025, revealed the facility failed to include the CPR code status. 9. Review of medical records revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Lymphedema, and Chronic Ischemic Heart Disease. Review of the POST form dated 4/6/2021, revealed Resident #17 elected DNR, Comfort Measures, and No artificial nutrition by tube. Review of significant change MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #17 was severely cognitively impaired. Review of the Care Plan dated 1/28/2025, revealed the facility failed to include the CPR code status. 10. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Coronary Artery Disease, Diabetes, Hypertension, Congestive Heart Failure, and Cardiac Pacemaker. Review of facility document titled, Advanced Care Plan, dated 7/10/2017, revealed an assigned agent to make health care decisions for Resident #19, and an alternate agent to make health care decisions for Resident #19, effective only when Resident #19 no longer had the capacity, included Quality of Life, Treatment, and Organ Donation directives per Resident #16's decisions. Review of the POST form dated 1/21/2019, revealed Resident #19 elected CPR, Limited Additional Interventions, and a Defined trial period of artificial nutrition by tube. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #19 was cognitively intact. Review of the Care Plan dated 2/24/2025, revealed the facility failed to include the CPR code status. 11. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Aphasia, and Osteoarthritis. Review of the POST form dated 6/28/2024, revealed Resident #22 family member elected DNR, limited additional interventions, and no artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated Resident #22 was severely cognitively impaired. Review of the Care Plan dated 1/20/2025, revealed the facility failed to include CPR code status. 12. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE], with diagnoses including Chronic Diastolic Heart Failure, Atherosclerotic Heart Disease, and Bipolar Disorder. Review of the POST form dated 10/16/2023, revealed Resident #25 elected DNR, comfort measures, and no artificial nutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #25 was severely cognitively impaired. Review of the Care Plan dated 3/5/2025, revealed the facility failed to include the CPR Code Status. 13. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety Disorder and Depression. Review of the POST form dated 10/16/2024, revealed Resident #27 elected DNR, Comfort Measures, and no artificial nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 9, which indicated Resident #27 was moderately cognitively impaired. Review of the Care Plan dated 2/10/2025, revealed the facility failed to include CPR code status. 14. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Methicillin Susceptible Staphylococcus, Cellulitis, Benign Prostatic Hyperplasia, Urinary Retention, and Testicular Hypofunction. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #29 was cognitively intact. Review of the POST form dated 3/17/2025, revealed Resident #29 elected CPR. Review of the Care Plan dated 3/18/2025, revealed the facility failed to include the CPR code status. 15. Review of the medical record revealed Resident #32 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure, Dysphagia, and Dementia. Review of the POST form dated 4/7/2023, revealed Resident #32's Power of Attorney (POA) elected DNR, limited additional interventions, and no artificial nutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #32 was cognitively intact. Review of the Care Plan dated 2/10/2025, revealed the facility failed to include the CPR code status. 16. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses including Fracture of Left Femur, Orthopedic Aftercare, Repeated Falls, and Acute Kidney Failure. Review of the POST form dated 2/4/2025, revealed Resident #33 elected CPR and Full Treatment. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #33 was cognitively intact. Review of the Care Plan dated 3/6/2025, revealed the facility failed to include the CPR code status. 17. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE], with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Major Depressive Disorder and Type 2 Diabetes Mellitus. Review of the POST form dated 4/24/2023, revealed Resident #34 elected DNR, Comfort Measures, and no artificial administered nutrition by tube. Review of the quarterly MDS assessment dated [DATE], revealed a score of 00, which indicated Resident #34 was severely cognitively impaired. Review of Care Plan dated 2/20/2025, revealed the facility failed to include the CPR code status. 18. Review of the medical record revealed Resident #45 was admitted to facility on 5/7/2024, with diagnoses including Hypertension, Chronic Kidney Disease, Myocardial Infarction, and Diabetes. Review of the medical record revealed Resident #45 had a Durable Health Care Power of Attorney dated 12/1/2022. Review of the POST form dated 9/26/2024, revealed Resident #45 elected CPR, Full Treatment, and a Defined trial period of artificial nutrition. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #45 was severely cognitively impaired. Review of Care Plan dated 2/5/2025, revealed the facility failed to include CPR code status. 19. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Fracture of Left Femur, Tachycardia, Severe Protein-Calorie Malnutrition, and Alzheimer's Disease. Review of the POST form dated 2/4/2015, revealed Resident #48's daughter was appointed as agent for decision making to include medical treatments and health care decisions. Review of the POST form dated 1/24/2025, revealed Resident #48 elected DNR, Comfort Measures, and No Artificial Nutrition by tube. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #48 was severely cognitively impaired. Review of the Care Plan dated 2/18/2025, revealed the facility failed to include the CPR code status. 20. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE], with diagnoses including Cellulitis of Right Lower Limb, Cellulitis of Left Lower Limb, acute Kidney Failure, and Diabetes. Review of the Care Plan dated 2/4/2025, revealed the facility failed to include the CPR code status. Review of the POST form dated 2/10/2025, revealed Resident #51's preference for CPR, Full Treatment, and a Defined trial period of artificial nutrition by tube. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #51 was cognitively intact. 21. Review of the medical record revealed Resident #207 was admitted to the facility on [DATE], with diagnoses including Pneumonitis due to Inhalation of Food and Vomit, Sepsis, Chronic Obstructive Pulmonary Disease, Acute Kidney Failure, Cystitis, Dysphagia, and Hypertension. Review of the facility document titled, Durable General Power of Attorney, dated 9/21/2022, revealed Resident #207's son had Durable General Power of Attorney to include medical. Review of the facility document titled, Health Care Directive (Living Will), dated 9/21/2022, revealed Resident #207's son was appointed as agent for all matters relating to health with no concerns noted. Review of the Care Plan dated 3/17/2025, revealed the facility failed to include the CPR code status. 22. Review of the medical record revealed Resident #257 was admitted to the facility on [DATE], with diagnoses including Multiple Fractures of Pelvis with Stable Disruption, Fatty Liver disease, and Opioid Dependence. Review of the POST form dated 3/26/2025, revealed Resident #257 elected CPR, Full Treatment, and a Defined trial period of artificial nutrition by tube. Review of the Care Plan dated 3/26/2025, revealed the facility failed to include the CPR code status. 23. During an interview on 3/25/25 at 10:12 AM, the MDS Coordinator stated, .I usually don't care plan a resident's DNR status . During an interview on 3/27/2025 at 7:50 PM, the DON was asked if a resident's care plan should be person centered. The DON stated, Yes. The DON was asked if the code status would be a part of the person centered care plan. The DON stated, .it would be important to have the post form on the chart . 24. Review of the medical record revealed Resident #18 admitted to the facility on [DATE], with diagnoses including Dementia, Major Depressive Disorder, and Osteoporosis. Review of the Quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #18 was severely cognitively impaired, required partial/moderate assistance with sit to stand and chair/bed-to-chair transfers, and had sustained 2 falls since admission. Review of Resident #18's comprehensive care plan dated 3/26/2025, revealed a focus for falls. Resident #18 had a total of eleven falls (5/10/2024, 8/30/2024, 9/12/2024, 9/18/2024, 9/22/2024, 9/24/2024, 10/9/2024, 10/21/2024, 12/11/2024, 1/1/2025, and 3/9/2025.) An intervention for Frequent Flyers (patients at high risk for falls will have a plane placed on the outside of the patient's door to alert staff)was dated 5/10/2024. During an interview on 3/27/2024 at 12:40 PM, Certified Nursing Assistant (CNA) A was asked to explain the frequent flyer program. CNA A stated, .the airplane picture or the plastic airplane on the door lets the staff know the resident is at high risk for falls .not to leave the resident alone .toilet them frequently .check on them frequently . During an observation and interview on 3/27/2025 at 12:45 PM, CNA A and Registered Nurse (RN) D were asked if Resident #18 had an airplane on her door to alert the staff she was a high fall risk, both employees stated, .No . During an interview on 3/27/2025 at 7:50 PM, the DON was asked if Resident #18's intervention for falls was to place her on the frequent flyer program. The DON stated Yes. The DON was asked if Resident #18 should she have an airplane on her door to alert staff. The DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to store foods in a safe and sanitary manner as evidenced by expired foods in the walk-in refrigerator and on the shelf in the dry storage room and serve food in a safe and sanitary manner for 1 of 30 residents (#31) during the lunch meal on 10/27/19. The findings include: Facility policy review, Date Marking for Food Safety, undated, revealed .The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest .The Head Cook, or designee, shall be responsible for checking daily for food items that are expiring, and shall discard accordingly . Facility policy review, Handling Serving a Meal, undated, revealed .Avoid handling actual unwrapped food items with bare hands . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Mood Disorder Due To Known Physiological Condition With Depressive Features and Blindness, One Eye. Further medical record review of Resident #31's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #31 required set up supervision with eating. Observation on 10/27/19 at 8:45 AM in the kitchen walk-in refrigerator with the Certified Dietary Manager (CDM), Food Service Director (FSD), revealed Mustard Potato Salad, 11 pound (LB) container and Cottage Cheese, 11 LB container, use by date 10/14/19. Observation on 10/27/19 at 8:48 AM in the kitchen dry storage with the Certified Dietary Manager, FSD, revealed 24-8 fluid ounce (237 OZ) containers of Thicken Dairy Drink, expiration date 10/17/19. Observation on 10/27/19 in the Magnolia Dining Room at 12:30 PM revealed Certified Nurse Assistant (CNA) #3 setting up Resident #31's lunch tray and touched Resident #31's sandwich with her left bare hand to reposition the sandwich, then she secured the sandwich with her left bare hand to cut it, then she picked up half of the sandwich with her left bare hand to give it to the resident. Observation and interview with the CDM on 10/27/19 at 8:45 AM in the walk in refrigerator and at 8:48 AM in the dry storage area confirmed the mustard potato salad, cottage cheese and the thickened dairy drink were expired. Interview with CNA #3 on 10/27/19 at 12:33 PM in the Magnolia Dining room revealed CNA #3 when asked what was the process of handling a resident's food when setting up the meal, she stated, I was not supposed to touch the food with my hands. Interview with the Director of Nursing on 10/28/19 at 10:37 AM in her office confirmed staff were not to touch food with bare hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to obtain physician orders for oxygen for 1 resident (#54) of 13 residents receiving respiratory treatment. The findings include: Medical record review revealed Resident #54 was admitted to the facility on [DATE], was discharged on 10/10/18 to the hospital, was readmitted to the facility on [DATE] with diagnoses include Chronic Heart Disease and Chronic Obstructive Pulmonary Disease. Observation on 11/5/18 at 9:49 AM, at 3:58 PM, and 4:01 PM, and on 11/6/18 at 8:12 AM, revealed Resident #54 in the room, in bed, with the oxygen concentrator in operation. Further observation revealed the resident was receiving the oxygen at 2 liters per minute by a nasal cannula. Observation on 11/5/18 at 12:50 PM revealed Resident #54 with a nasal cannula in place, in a wheelchair in the main dining room receiving oxygen from a portable oxygen tank set at 2 liters per minute. Medical record review of the physician orders revealed no order for oxygen. Interview with Licensed Practical Nurse (LPN) #2 on 11/6/18 at 8:48 AM at the 100/200 nursing station revealed the LPN was responsible for Resident #54 and the resident was receiving oxygen. Further interview confirmed the medical record did not have a physician order for the oxygen for Resident #54. Further interview revealed the facility utilized Standing Orders which included .When a patient having difficulty breathing or has oxygen saturation less than 88% (percent), apply Oxygen at 2 liters and contact MD . Further interview confirmed the medical record did not have a Standing Order form signed by the physician. Interview with LPN #3, Nurse Manager, on 11/6/18 at 9:13 AM at the 100/200 nursing station confirmed the medical record for Resident #54 did not contain physician order or signed Standing Order form for oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to label and date oxygen and nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) tubing and humidified canisters for 1 resident (#11) of 13 residents reviewed receiving respiratory treatments. The findings include: Review of the facility policy Departmental (Respiratory Therapy)-Prevention of Infection, revised 4/07 and addendum dated 7/28/10, revealed .Keep the oxygen cannulae and tubing used PRN [as needed] in a plastic bag when not in use [Nebulizers/Continuous Aerosol, store the circuit in a plastic bag, marked with date and resident's name, between uses] Discard the administration set up every 7 days [Oxygen cannulas will be changed every two weeks and as needed and whenever visibly soiled] whenever a cannula /mask is not in use it is to be placed in a zip lock bag on the concentrator . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses included Chronic Kidney Disease Stage 4, Chronic Congestive Heart Failure and Hypertension. Medical record review of the November 2018 physician orders revealed .PRN 02 [oxygen] @ [at] 2L/min [liters per minute] via NC [nasal cannula] for 02 sats [saturation] below 90% [percent] . Medical record review of the Quarterly Minimum Data Set (MDS) for Resident #11 dated 10/19/18 revealed the resident was receiving oxygen therapy. Observations on 11/5/18 at 10:01 AM, 11:49 AM, 2:59 PM and 4:08 PM, revealed Resident #11 had an oxygen concentrator in her room not in use with the oxygen tubing and humidified water canister not dated. Further observation in the resident's room revealed Resident #11 had a nebulizer machine with tubing attached and the tubing not dated or stored in a plastic bag. Observation of Resident #11 on 11/5/18 at 4:08 PM in the resident's room with Licensed Practical Nurse (LPN) #1 present revealed the resident's oxygen tubing, nebulizer tubing, and humidified water canister were not dated. Further interview with LPN #1 confirmed the oxygen tubing, humidified water, and nebulizer tubing were to be changed and dated weekly. Interview with the Director of Nursing (DON) on 11/6/18 at 8:17 AM in her office confirmed oxygen tubing and humidified water canisters were to be changed and dated every two weeks and nebulizer tubing were to be changed and dated weekly. Further interview with the DON revealed staff were to date tubing and bottles when changed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation and interview, the facility failed to properly secure a oxygen cylinder for 1 of 34 rooms observed. The findings include: Review of the undated facility policy Oxygen Safety revealed .Cylinders will be properly chained or supported in racks or other fastenings to secure all cylinders from falling, whether connected, unconnected, full or empty . Observation on 11/5/18 at 9:10 AM and 9:50 AM in room [ROOM NUMBER] revealed an oxygen cylinder on the floor standing up in front of a wheelchair unsupported. Interview with the Director Of Nursing (DON) on 11/5/18 at 5:16 PM in her office revealed she was not aware of the oxygen cylinder on the floor, not appropriately stored. The DON confirmed the oxygen cylinder should be stored when not in use, and when they are in use they are supposed to be stored in the cylinder holder. \