**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to educate and provide written information to residents regarding a right to formulate an advanced directive for 4 of 24 residents (Residents #24, #36, #75, and #239) reviewed. The findings include: 1.Review of the facility's policy titled, Advance Directives, dated 11/1/2016, revealed .[Named facility] recognizes the right of each resident to issue Advance Directives regarding his or her health care .and a right to formulate, at the individual's option, an Advance Directive .will provide Residents with information regarding Advance Directives at admission .If a Resident is incapacitated .unable to receive information about Advanced Directives or articulate whether he/she has an Advance Directive .will provide information regarding Advance Directives to the Resident's family or Resident Representative .will document in the Resident's medical record whether or not the Resident has executed an Advance Directive . 2.a. Review of the medical records revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Congestive Heart Failure, Diabetes, and Chronic Obstructive Pulmonary Disease. Review of the annual MDS assessment dated [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The facility was unable to provide completed documentation that the resident was educated regarding advanced directives and/or to formulate an advance directive. b. Review of the medical records revealed Resident #36 was admitted to the facility on [DATE], with diagnoses of including Diabetes, Heart Failure, and Kidney Failure. Review of the quarterly MDS assessment dated [DATE], revealed Resident #36 had BIMS score of 15, which indicated intact cognition. The facility was unable to provide completed documentation that the resident was educated regarding advanced directives and/or to formulate an advance directive. c. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including Dementia, Alzheimer's, and Bipolar Disorder. Review of the significant change in status MDS assessment dated [DATE], revealed Resident #75 BIMS score of 13, which indicated intact cognition. The facility was unable to provide completed documentation that the resident was educated regarding advanced directives and/or to formulate an advance directive. d. Review of the medical record revealed Resident #239 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Kidney Failure, and Heart Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #239 had a BIMS score of 15, which indicates intact cognition. The facility was unable to provide completed documentation that the resident was educated regarding advanced directives and/or to formulate an advance directive. During an interview on 4/2/2025 at 10:58 AM, the Administrator confirmed that she had provided everything she had related to advanced directives. The facility was unable to provide documentation that the residents were educated and provided written information regarding their right to formulate an advanced directive.

**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 ensure residents were free of physical restraints for 1 of 1 (Resident #29) sampled residents reviewed for restraints. The findings include: 1. Review of the facility policy titled, Physical Restraint Guideline, dated 6/2017, revealed .For each patient/resident to maintain his or her highest practical health or well being in an environment that prohibits the use of restraints .and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints .Upon determination a patient/resident presents with medical symptoms that may require a restraint, they are evaluated .The Care Plan .is reviewed .revised to include restraint use. 2. Review of the medical record review revealed Resident #29 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Repeated Falls, Dementia, and Anxiety. Review of an Order Summary Report dated 8/19/2022, revealed .self release alarm seat belt to wheelchair every day and night shift for preventative . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #29 was rarely/never understood and severely cognitively impaired. She is dependent on staff for all activities of daily living. Resident #29 is not assessed for a trunk restraint. Review of the Care Plan dated 4/1/2025, revealed Resident #29 was at risk for falls, with an intervention in place dated 11/30/2022, with education regarding self release seatbelt. Observation on 3/31/2025 at 10:58 AM and 2:58 PM, 4/1/2025 at 7:54 AM and 1:37 PM, and 4/2/2025 at 7:49 AM, revealed Resident #29 was sitting up in her wheelchair with a self release waist belt intact. Observation and interview on 4/2/2025 at 9:02 AM, the DON and Unit Manager took Resident #29 to her room. Resident #29 was asked and encouraged to release her waist belt several times, she was pleasantly confused and unable to release the belt. The DON at this time confirmed Resident #29 has a restraint on and she should be monitored and assessed for a restraint. DON stated, I will call her daughter and probably remove it. During an interview on 4/5/2025 at 8:57 AM, the Director of Nursing (DON) was asked if Resident #29's self release belt was a restraint. The DON stated, No, because she can take it off depending on her mood .her daughter insists she has this on due to previous falls .

Based on the facility's Clinical Skills Fair Guide, observation, and interview, the facility failed to use proper supplies when 1 of 5 nurses (Licensed Practical Nurse (LPN) A) administered medication from a flex pen during medication administration. The findings include: 1. Review of the [Named Facility] Clinical Skills Fair Guide, page 32 FLEX PEN [a pre-filled insulin delivery device] COMPETENCY AUDIT AND ADMINISTRATION GUIDE . revealed .REQUIRED MATERIALS .FlexPen .FLexPen needles .Removes the cover from the syringe .Opens new needle .screws the needle onto the FlexPen .Dials the number of units needed to inject .1 click=[equals] 1 unit of insulin .injects insulin by pressing the push button all the way in .Leaves the needle under the skin for at least 10 second after injecting insulin .Keep the button fully depressed until withdrawing the needle .Removes the needle from the pen . 2. An observation and interview during medication administration on 4/1/2025 at 4:43 PM, revealed LPN A took a FlexPen from the medication cart drawer and used an insulin syringe to draw up the medication from the FlexPen into the insulin syringe. LPN A was asked why she drew the insulin out of the FlexPen and did not put a needle on the FlexPen and administer the medication that way. LPN A stated, .ran out of needles for the FlexPens a few days ago .this happened in January, and we were told to do it this way . During an interview on 4/1/2025 at 5:15 PM the Director of Nursing (DON) was asked if she knew they did not have needles for the FlexPens and the staff was using insulin syringes to draw the medication out of the FlexPen to administer insulin to the Residents. The DON stated, I was unaware they were out of needles for the insulin pens . She stated that this happened earlier in the year and the pharmacy said they could do that. When asked who she talked to she was unsure. During a telephone interview on 4/2/2025 at 12:40 PM, the Pharmacist stated that none of the pharmacists recall a conversation about drawing insulin from the FlexPen with an insulin syringe.

**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 properly stored and secured when medications were found unsecured and unattended in 2 of 57 (Residents #23 and #47) resident occupied rooms. The findings include: 1. Review of the facility policy titled, MEDICATION STORAGE IN THE FACILITY POLICY, dated 4/2025, revealed .Medications and biologicals must be stored safely, securely, and properly .BEDSIDE MEDICATION STORAGE .Written order in the medical record .Document on MAR [Medication Administration Record] and care plan .store in original/pharmacy containers . 2. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia, Depression and Anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated Resident #23 was moderately cognitively impaired. Review of the Self Administration of Medications, evaluation dated 2/3/2025, revealed .Flonase .Storage .With staff .Resident may self administer medications WITH SUPERVISION .Medication will be stored on med-cart . Review of the care plan updated 3/31/3025, revealed .Medications will be stored in a secure location. Location: med cart . Observation on 3/31/2025 at 9:05 AM, revealed 1 bottle labeled Fluticasone (nasal spray used for allergies) was on the nightstand in Resident #23's room. During an interview on 3/31/2025 9:19 AM, LPN A was asked if medications should be stored at the bedside. Licensed Practical Nurse (LPN) A stated, No During an interview on 3/31/2025 at 2:51 PM, the Administrator was asked if medications should be stored at the bedside. She stated, .no, I heard about that . 3. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident was cognitively intact. An observation and interview on 4/2/2025 at 8:35 AM, revealed a clear medication cup with a white powder in it on a storage bin in Resident #47's room. The Resident was asked what the powder in the medication cup was. She stated, Nystatin [antifungal] powder that they put under my breast at night before bed. LPN B was asked if medication should be stored at the bedside. She stated, No. During an interview on 4/2/2025 at 9:02 AM, the Director of Nursing (DON) confirmed medication should not be stored at the bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility Infection Control Guide, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 nurse (Licensed Practical Nurse (LPN C) failed to wear Personal Protective Equipment (PPE) in an enhanced barrier precautions room. The findings include: 1. Review of the facility manual, [Named Facility] Infection Control Guide, on pages 7 and 8, dated 2025, revealed .Enhanced Barrier Precautions .refers to .the expanded use of PPE during high-contact resident activities .residents with wounds .are at especially high risk .the use of gown and gloves for high-contact resident care activities is indicated . 2. Review of the medical record review revealed Resident #77 was admitted to the facility on [DATE], with diagnoses including Pressure Ulcer, Cerebrovascular Disease with Hemiplegia (paralysis on one side of the body), Heart Failure, Peripheral Vascular Disease, Hypertension, and Cachexia (muscle wasting). Review of the Order Summary Report dated 1/15/2025, revealed .Front Left Lateral Leg Stage IV (4) Pressure Ulcer: Cleanse with wound cleanser, pat dry with gauze .apply Negative Pressure Wound Therapy Vac (vacuum) . Monday .Wednesday, Friday . An observation during pressure ulcer care on 4/2/2025 at 9:40 AM, revealed LPN C performed Resident #77's left lower leg ulcer treatment without a PPE gown on in an enhanced barrier room. During an interview on 4/2/2025 at 11:55 AM, (Registered Nurse (RN) D) was asked if a nurse was performing pressure ulcer care on a resident should they wear PPE in an enhanced barrier room. RN D stated, Yes, you should.

**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 feeding syringes were properly labeled for 2 of 4 sampled residents (Resident #47 and #298) reviewed for tube feedings. The findings include: Review of the facility's undated policy titled, Medication Administration Competency Audit, revealed .Cleans feeding syringe and return to bedside stand. Syringes are replaced after 24 hours or by state regulation . Review of the medical record, revealed Resident #47 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbances, Major Depressive Disorder, Dementia, Schizophrenia, Muscle Weakness, Atrial Fibrillation, Hypertension, Cerebral Infarction, Hemiplegia, Hemiparesis, Dysphagia. Review of the Physician's Orders dated 6/8/2021, revealed .Enteral Feed Order three times a day Bolus 1 can (8 oz [ounce]) of Jevity 1.5 Cal [calorie] if < [less than] 50% [percent] of meal consumed. Change feeding tubing and syringe every 24 hours and label with date/time/feeding and rate every night shift .Flush peg tube with 30 cc [cubic centimeters] water before and after medication administration and 10 cc of water between medications every shift . Review of the June 2021 Medication Administration Record (MAR), revealed Resident #47 received an enteral bolus feeding 1 (8 oz) can of Jevity 1.5 Cal on 6/16/2021 at 8:00 AM. Observation in the resident's room on 6/14/2021 at 9:50 AM, revealed a feeding syringe in a plastic sleeve labeled with only Resident #47's last name, not dated or timed, laying on the nightstand. Observation in the resident's room on 6/16/2021 at 8:01 AM, revealed a feeding syringe in a plastic sleeve, labeled with Resident #47's last name and dated 6/15/2021, but not timed, laying on the nightstand. Review of the medical record, revealed Resident #298 was admitted on [DATE] with diagnoses of Cerebral Infarction, Dysphagia, Dysarthria, Aphasia, Hemiplegia. Review of the Physician's Orders dated 6/3/2021, revealed .Enteral Feed every shift Jevity 1.2 Cal at 55 cc/hr [hour] x [times] 22 hours with 25 cc auto flush water .Change Gastric tube feeding bottle, water flush tubing set, and flush syringe. Label with Resident's name, date, time, and feeding infusion rate one time a day every night shift. May administer crushed medications per gastric tube . Observation in Resident #298's room on 6/16/2021 at 7:57 AM, revealed a feeding syringe in a plastic sleeve, labeled with a date of 6/15/2021, no name or time, in a plastic sleeve laying on the bedside table. Observation in Resident #298's room on 6/16/2021 at 12:15 PM, revealed a feeding syringe in a plastic sleeve labeled with a date of 6/15/021, no name or time, laying on the bedside table. During an interview on 6/16/2021 at 12:11 PM, Licensed Practical Nurse (LPN) #3 confirmed that feeding syringes should be changed daily by night shift and replaced if not labeled correctly. During an interview on 6/16/2021 at 5:58 PM, the Director of Nursing (DON) confirmed the feeding tube syringes should be changed daily by the night shift and should be labeled with the resident's name, room number, and date and time. The DON was asked what staff should do if a syringe is in the room labeled with the previous day's date. The DON stated, Put a new one on [Get a new syringe].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Geriatric Medication Handbook, medical record review, observation, and interview, the facility failed to ensure a resident was free from a significant medication error when 1 of 2 nurses (Licensed Practical Nurse (LPN) #2) failed to administer insulin within the proper time frame related to meals for Resident #24. The failure to provide a substantial meal or snack within 15 minutes of insulin administration resulted in a significant medication error. The findings include: Review of the Geriatric Medication Handbook, tenth edition, page 43 revealed .DIABETES: INJECTABLE MEDICATIONS .Novolog .Rapid-Acting Insulin Analog .ONSET .15 min [minutes] .[administer] 5-[to]10 minutes .prior to meals . Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnosis of Intestinal Obstruction, Dysphagia, Diabetes Mellitus, Peripheral Vascular Disease, Constipation, Hypertension, Colitis and Gastroenteritis. Review of the Order Review History Report, dated 6/16/2021, revealed .NovoLOG Mix 70/30 FlexPen Suspension Pen-injector (70-30) 100 UNIT/ML [millimeter]15 unit subcutaneously two times a day for Blood glucose control . Observations in the resident ' s room on 6/14/2021 at 7:02 AM, revealed LPN #2 administered 15 units of Novolog insulin to Resident #24. Observations in the resident's room on 6/14/2021 at 7:52 AM, revealed Resident #24 took her first bite of a fudge snack cake which was 50 minutes after Resident #24 received the insulin. During an interview on 6/15/2021 at 7:45 AM, the Director of Nursing (DON) confirmed that the resident should receive a snack or tray within 15 minutes of administrating insulin .

Based on policy review, observation, and interview the facility failed to ensure food was stored and distributed in a manner to prevent the spread of infection when unlabeled and expired foods were found in a refrigerator in the Kitchen, and when 4 of 21 staff members (Certified Nursing Assistant (CNA) #1 and #3, Licensed Practical Nurse (LPN) #3 and Nursing Assistant (NA) #1) touched residents' food, failed to appropriately sanitize their hands, and failed to wear appropriate Personal Protective Equipment (PPE) during meal service. This had the potential to affect the 96 of the 97 residents who had received a tray from the Kitchen. The findings include: The facility's undated policy titled, Labeling and Dating, revealed .Food labels must include: The food item name .The date of preparation .The 'use by' date .Leftovers must be labeled and dated with the date they are prepared and the 'use by' date .foods that are held for more than 24 hours at a temperature of 40 [degrees] F [Fahrenheit] or less, will be labeled and dated with a 'prepared date' (Day 1) and a 'use by' date (Day 7) . The facility's undated policy titled, System of Isolation Precautions for Infection Control revealed .Contact .Gloves required upon entering room .Gown required if clothing may come into contact with patient/resident or environmental surfaces . Review of the facility's IN-SERVICE TRAINING RECORD, dated 12/11/2020 revealed .Yellow Zone .You must DON [put on] your PPE [Personal Protective Equipment: gowns, gloves, face mask] (gowns), gloves, N95 [a filtering face piece respirator], eyewear when entering each room .Everyone, every time . Observation in the Kitchen during initial tour on 6/14/2021 at 5:25 AM, revealed the following items stored in a refrigerator: a. 1 unlabeled, undated container of chicken and dumplings. b. 1 container of brown gravy labeled with a preparation date of 6/6/2021, and a use by date of 6/9/2021. c. 1 container of meat sauce labeled with a use by date of 6/11/2021. d. 2 open bags of turkey sandwich meat with no opened dates. e. 1 container of chicken gravy labeled 5/4/7/2021. f. 1 container of yellow cheese slices labeled with a preparation date of 5/17/2021, and a use by date of 5/20/2021. g. 1 container of orange slices in juice labeled with a use by date of 5/14/2021. h. 1 unlabeled, undated container of brown meat chunks. During an interview on 6/14/2021 at 5:30 AM, Dietary Aide #1 confirmed that the chicken gravy was not labeled appropriately, was prepared on 5/4/2021 and should have been discarded. Dietary Aide #1 was asked if she could identify the brown meat chunks in the unlabeled container. Dietary Aide #1 stated, I'm not sure . Observation in the Kitchen on 6/14/2021 at 1:08 PM, revealed the following items remained in the refrigerator: a. 2 open bags of turkey sandwich meat, not labeled with opened dates. b. 1 container of yellow cheese slices labeled with a preparation date of 5/17/2021 and a use by date of 5/20/2021. During an interview on 6/14/2021 at 1:10 PM, the Assistant Dietary Manager stated, .I don't think that date [on the container of cheese] is correct. I think they put food in containers, after they are washed, and don't change the labels . The Assistant Dietary Manager confirmed that opened items stored in the refrigerator should be labeled with an opened or prepared date. Observation in the Kitchen on 6/16/2021 at 4:10 PM, revealed 1 container of yellow cheese slices dated with a prepared date of 5/17/2021, and a use by 5/20/2021 still in the refrigerator. During an interview on 6/16/2021 at 4:11 PM, the District Dietary Manager confirmed the container of cheese was not properly labeled and that items should not be in the refrigerator after the use by date. Observation in the 600 Hall Dining Room on 6/14/2021 at 7:50 AM, revealed CNA #1 picked up Resident #11's biscuit off of the plate, opened the biscuit with her bare hand, spread butter and jelly on the biscuit, closed it, and placed it back on the plate. Observation in the 600 Hall Dining Room on 6/14/2021 at 7:52 AM, revealed CNA #1 touched Resident #18 on her shoulder, then picked up the biscuit off the tray, opened the biscuit with her bare hand, spread butter and jelly on the biscuit, closed it and placed it back on her plate. During an interview on 6/15/2021 at 12:59 PM, CNA #1 confirmed that she should not handle the resident's food with bare hands during dining. Observation on the 100 Hall on 6/14/2021 at 7:50 AM, revealed the doors were closed with a sign on the door indicating it was a Yellow Zone. Isolation signs posted on the outside of the hall doors and on the doors of all occupied rooms revealed, Contact Precautions everyone must: Clean their hands, including before entering and when leaving room. Providers and staff must also: put on gloves before entry .put on gown before entry . and Droplet Precautions everyone must .make sure eyes, nose and mouth are fully covered before entry . Observation on the 100 Hall on 6/14/2021, beginning at 7:52 AM during dining, revealed NA #1 entered Resident #296's room wearing a surgical mask, but not wearing a gown, gloves, N95 mask or eye protection, NA #1 exited the room and failed to perform hand hygiene. NA #1 removed a tray from the cart and entered Resident #297's room, without donning proper PPE. NA #1 placed the tray on the bedside table, then exited the room, and failed to perform hand hygiene and exited the 100 Hall. NA #1 returned to the 100 hall with a cup of coffee and delivered it to Resident #297's room, without donning proper PPE. NA #1 then exited Resident #297's room, and failed to perform hand hygiene and exited the 100 Hall. NA #1 then returned to the 100 hall, and without donning proper PPE, entered Resident #297's room. Observation on the 100 Hall on 6/14/2021 at 8:01 AM, revealed NA #1 was wearing a surgical mask, delivered a tray to Resident #347's room, without donning proper PPE, then exited the room and failed to perform hand hygiene. Observation in the 600 Hall Dining Room on 6/15/2021 at 12:39 PM, revealed that LPN #3 served 4 resident trays without performing hand hygiene. Observation on the 100 Hall during meal service on 6/15/2021 at 12:42 PM, revealed CNA #3 passing meal trays wearing an N95 mask. CNA #3 delivered trays to Resident #296 and Resident #347's rooms without donning eye wear, gown, or gloves. CNA #3 then proceeded down the hall with tray cart, stopped outside Resident #57's room, donned a gown and gloves, but no protective eye wear or face shield and entered Resident #57's room with a meal tray. Observation in the 600 Hall Dining Room on 6/15/2021 at 12:43 PM, revealed that LPN #3 served 5 resident trays without performing hand hygiene. During an interview on 6/15/2021 at 1:00 PM, LPN #3 confirmed that she should have used hand sanitizer between every third resident. During an interview on 6/16/2021 at 9:21 AM, the Director of Nursing (DON) confirmed that the staff members should not touch resident's food with their bare hands. The DON confirmed that when serving trays in the Dining Room, the staff members should sanitize their hand after each resident. During an interview conducted on 6/16/2021 at 9:24 AM, the DON confirmed that staff should wear N95 masks and full PPE, including gown, gloves and eye protection when entering resident rooms in the Yellow Zone of the 100 Hall.