**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review, observation and interview the facility failed to ensure dignity and resident choice was met for 1 (Resident #33) of 1 sampled resident reviewed for activities of daily living. The findings include: 1. Review of the undated facility policy titled, CALL LIGHTS, revealed, .It is the policy of the facility to have a system in placed to allow the staff to respond promptly to a resident's call for assistance .Never make the resident feel as though you are too busy to give assistance. If you yourself cannot provide the requested assistance, assure the resident that you will take their request to the appropriate staff. Follow through with this commitment and follow up to see if the resident had the need met. NEVER TURN OFF A CALL LIGH THEN FAIL TO SEE THAT THE RESIDENT'S REQUEST WAS ADDRESSED Review of the undated facility policy titled, Resident Rights, revealed, .The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident . 2. Review of the medical record revealed Resident #33 was admitted on [DATE], with diagnoses which included Muscle Wasting and Atrophy, Chronic Pain Syndrome, Need for assistance with personal care, and Anorexia. Review of the Annual Minimum Data Set assessment (MDS) dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #33 was dependent for chair/bed-to-chair transfer. During an observation and interview on 4/14/2025 at 3:50 PM, Resident #33 stated, leave the door open I want to see how long it takes her to come down here and put me to bed . Resident #33 turned on his call light at 3:50 PM. Observation on 4/14/2025 at 3:51 PM, revealed 2 staff members sitting at nurses' station where call light was sounding. Observation on 4/14/2025 at 3:57 PM, Resident #33 still awaiting to be placed in bed. Observation on 4/14/2025 at 3:58 PM, Wound Nurse answered the call light and told the resident I will go see if I can find your Certified Nursing Assistant (CNA). Observation on 4/14/2025 at 3:59 PM, Resident #33 continued to wait to be placed in his bed. Observation on 4/14/2025 at 4:04 PM, Resident #33 had rolled into the hall still awaiting to be placed in bed. Observation on 4/14/2025 at 4:05 PM, a CNA takes him into his room then walked back out. Observation on 4/14/25 at 4:08 PM, Resident #33 continued to sit in his wheelchair by his bed. Observation on 4/14/25 at 4:11 PM, Resident #33 continued to be up in his wheelchair. Observation on 4/14/2025 at 4:12 PM revealed 3 staff members are sitting at the nurse's station. Observation on 4/14/2025 at 4:13 PM, the Wound Nurse told Resident #33, I am looking for the CNA so I can help put you to bed. Observation and interview on 4/14/2025 at 4:14 PM, Resident #33 stated, .this is always a problem when I get back from smoking . Observation on 4/14/2025 at 4:16 PM, Resident #33 had been waiting 26 minutes to be put to bed. Observation on 4/14/2025 at 4:16 PM, the CNA was standing at the desk which he told at 4:05 PM, he wanted to go to bed. Observation on 4/14/2025 at 4:19 PM, Resident #33 continued to remain up in his room in his wheelchair. During an interview on 4/15/2025 at 8:08 AM, Resident #33 stated, .I finally went to bed after about 2 hours. It seems to happen every time that CNA is here . Observation on 4/15/2025 at 1:45 PM, Resident #33's call light was on and sounding at the nurse's station. Resident #33 stated, .I am waiting to go back to bed .I went to smoke at 1:00 PM, I been waiting about 15 minutes . Observation on 4/15/2025 at 1:48 PM, CNA E answered Resident #33's call light and told the resident let me go see if I can find your CNA, referring to the CNA assigned to him today. CNA E goes to room [ROOM NUMBER] where his CNA was providing care. CNA E told the CNA he was wanting to go to bed through the door. CNA E stated, I will let him know you're in another room. CNA E goes back to Resident #33's room and informed him the CNA was in another resident's room providing care. Observation on 4/15/2025 at 1:54 PM, Resident #33 continued to be up in his wheelchair waiting to be placed in the bed. Observation on the hall on 4/15/2025 at 1:58 PM, CNA F (CNA assigned to Resident #33) came out of room [ROOM NUMBER] where she had been providing care. CNA F goes to Resident #33's room and told the resident .I will have to go find someone to help . Observation on hall on 4/15/2025 at 2:05 PM, CNA F and another care giver goes into Resident #33's room. Resident #33 had waited 20 minutes. Observation on 4/15/2025 at 2:10 PM, Resident #33 was in the bed. During an interview on 4/16/2025 at 11:50 AM, the Director of Nursing (DON) was asked what she expected staff to do when a call light is on. The DON stated, .I would expect them to answer it timely .they should meet the residents need .a CNA should not say let me find your CNA .the call light should be left on until their needs are met .I would expect the staff to provide the care even if that was not their resident that was to long for a resident to wait to go to bed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to assess 1 of 1 resident (Resident #197) reviewed for self-administration of medication. The findings include: 1. Review of the undated facility policy titled, Medication Self Administration, revealed .procedures for determining if the resident can safely self-administer .Residents .will be assess at the time of admission .to determine if the practice is safe, based on the results of the Resident Assessment-Self-administration Tool .assessment results will be discussed with the attending physician and an order obtained to self-administer if appropriate . 2. Review of the medical record revealed Resident #197 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Respiratory Failure, and Liver Disease. Basic Interview for Mental Status had not been assessed due to recent admit and in process. Review of the Physician Order Sheet dated April 2025, revealed .Levalbuterol HCl Nebulization Solution 0.63 MG [milligrams] /3ML [milliliter] 6 ml inhale orally via nebulizer .related to Chronic Obstructive Pulmonary Disease . Observation in the Resident's room on 4/15/2025 at 7:41 AM, Resident #197 was sitting on the edge of the bed with the nebulizer mask on and treatment going, and no nurse was present in the room. Observation on 4/15/2025 at 7:49 AM, Licensed Practical Nurse (LPN) A entered Resident #197's room and discontinued the nebulizer treatment. During an interview on 4/15/2025 at 1:08 PM the Director of Nursing (DON) confirmed that there should be an assessment for self-administration and a physician order for a resident to self-administer medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview the facility failed to implement interventions on care plan for 1 of 3 (Resident #26) sampled residents reviewed for accidents. The findings include: Review of the medical record revealed Resident #26 admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), Dementia, Osteoarthritis, Difficulty in Walking, and History of Falling. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive abilities. Review of Resident #26's Progress Note dated 8/8/2024 revealed, .Note Text: Resident witnessed on floor beside bed. Bed was in low position. She states that she rolled over and slid onto the floor. She was lying on her right hip .Arms noted under her upper body. Legs straight .Nurse and CNA had been in resident's room [ROOM NUMBER] min prior to fall. She was lying in bed, facing the wall at that time . Review of Resident #26's current comprehensive care plan revealed, .I'm at Risk for Falls as evidenced by the following risk factors and potential contributing Diagnosis: COPD .emphysema; acute respiratory failure with hypoxia; anxiety disorder; major depressive disorder; CHF [Congestive Heart Failure]; difficulty in walking history of falls; need for assistance with personal care; reduced mobility; peripheral vascular disease; unspecified dementia . Continued review of Resident #26's care plan revealed an intervention dated 8/8/2024 for define borders to the bed. During an observation and interview on 4/14/2025 at 2:25 PM, Family Member (FM) G reported she has had numerous falls since she admitted . FM G pulled up Resident #26's sleeve and she was noted to have bruising to the right elbow and 3 steri strips (used to help seal a wound by pulling the two sides of skin together) were noted. Observation on 4/15/2025 at 10:05 AM, Resident #26 was in the bed sleeping. No device or mattress noted to follow the care plan intervention for define borders of bed to help prevent falls. During an observation and interview on 4/15/2025 at 10:10 AM, Certified Nursing Assistant (CNA) F was asked what would be in place to meet the fall intervention for defined borders for her bed. CNA F stated, .we use a pool noddle sometimes, bolsters or the mattress may be raised on the edge . CNA F was asked to assess Resident #26's bed for the defined border. CNA F verified Resident #26 does not have anything to define the borders to her bed. During an observation and interview on 4/15/2025 at 10:15 AM, the MDS Coordinator was asked what would consist of defined borders on a fall care plan. MDS Coordinator stated, .either pool noddle, rolled up blanket, or a certain kind of mattress . The MDS Coordinator was asked to observe Resident #26's bed and asked if the resident had the intervention in place to define the borders of her bed. The MDS Coordinator stated, .no, it should be on the bed . During an interview on 4/15/2025 at 10:20 AM, the Director of Nursing was asked if a resident has an intervention for define borders to prevent falls should it be followed. The DON stated, .Yes, it should be on the bed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policies, record review, observations, and interviews the facility failed to provide Oxygen therapy as ordered by the Physician for 1 of 1 (Resident #13) reviewed for Respiratory Care. The findings include: 1. Review of the undated facility policy titled, Oxygen Administration Guidelines, revealed, .Review order for oxygen administration to include .flow rate . Review of the facility policy titled, Guidelines For Physician Orders, dated 6/18/2023, revealed .It is the policy of the facility to follow the orders of the physician .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility . 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Acute Ischemic Heart Disease, Occlusion and Stenosis of Left Carotid Artery, Cerebral Infarction, and Hypertension. Review of the Care Plan dated 1/28/2025 revealed .Administer O2 [oxygen] as ordered per MD [Medical Doctor] .Observe concentrator and/or E [emergency] tank for correct setting of liter . Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 1, which indicated that Resident #13 was severely cognitively impaired. Further review revealed no shortness of breath and oxygen therapy was received. Review of the Physician's Orders dated 3/29/2025, revealed .Oxygen 3 L [liter] PRN as needed for SOB [Shortness of Breath] 3L prn to keep O2 Sat above 91% [percent] . Review of the Medication Administration Record (MAR) dated 4/2025, revealed no documentation of administration of PRN O2. During observations in Resident #13's room on 4/14/2025 at 12:00 PM and 3:09 PM and 4/15/2025 at 7:49 AM, revealed Oxygen concentrator set on 1.5-2 L. During interview and observation on 4/15/2025 at 8:02 AM Licensed Practical Nurse (LPN) C was asked what Resident #13 O2 orders was, LPN C stated, 2L. LPN C was asked to show the O2 orders, LPN C stated, .it changed to 3L . LPN C was asked to show what Resident #13 O2 was set on, LPN C changed O2 setting to 3L. During an interview on 4/15/2025 at 4:33 PM the Director of Nursing (DON) confirmed that staff was expected to follow Physician orders for O2 settings.

**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 PRN (as needed) psychotropic medications for 1 (Resident #26) of 5 sampled residents reviewed for unnecessary medications were limited to 14 days duration. The facility failed to obtain a physician's assessment or documented rationale for continued use of the medication. The findings include: 1. Review of the undated facility policy titled, GUIDELINES FOR PSYCHOTROPIC MEDICATION, revealed .Based upon each individual resident's comprehensive assessment, the facility will ensure that residents who have not previously been on a psychotropic drug (s) are not given these meds unless the medication is necessary to treat a specific condition/diagnoses .PRN [as needed] Orders for Psychotropic Medications: PRN orders for psychotropic drugs will be limited to 14 days, unless the physician identifies and documents rationale to extend he medication beyond 14 days. PRN antipsychotics drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication . 2. Review of the medical record revealed Resident #26 admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with Hypoxia, Chronic Diastolic Heart Failure, and Major Depressive Disorder. Review of the Order Review History Report dated 3/15/2025 - 4/15/2025, revealed an order for Lorazepam (Antianxiety medication give for Anxiety) Oral Tablet 0.5 mg (milligram) by mouth every 6 hours as needed for anxiety related to Acute Respiratory Failure with Hypoxia, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. Continued review revealed Resident #26 had an order for PRN antianxiety medication since 1/14/2025. Continued review revealed an order for Buspar HCl (Hydrochloride) give 10 mg tablet two times a day for anxiety routinely. Further review revealed an order for Lorazepam give 0.5 mg tablet two times a day for anxiety routinely. Review of the Medication Administration Record (MAR) dated 3/1/2025-3/31/2025 revealed monitoring of behaviors for crying, agitation, or refusing of care. No behaviors were noted during the month of 3/2025. Review of the MAR dated 4/1/2025-4/15/2025 revealed monitoring of behaviors for crying, agitation, or refusing of care. No behaviors were noted from 4/1/2025-4/15/2025. Review of the Consultant Pharmacist Communication to the Physician form for Resident #26 dated 3/2024 revealed .prn [as needed] lorazepam-Under CMS regulations that started November 2017, PRN psychoactive medications. including anxiolytics FOR ANY INDICATION are initially limited for 14 days. NO EXCEPTIONS ARE GIVEN FOR HOSPICE OR SEIZURES. AFTER 14 DAYS, THE ORDER MUST BE DISCONTINUED and the resident must be re-evaluated for continued need of therapy. The results of the evaluation should be documented in the resident's medical record, with any behaviors warranting continued use documented by the nursing staff. Please discontinue order and reevaluate this resident by 3/29/24 [3/29/2024] . Observation on 4/15/2025 at 8:19 AM, Resident #26 was noted to be drowsy sitting in the dining area and leaning to the left side of her wheelchair. Observation on 4/15/2025 at 8:25 AM, Resident #26 nodded off sitting in her wheelchair and awakened when her head nodded down. Observation on 4/15/2025 at 8:28 AM, Resident #26 was served her breakfast, and a staff member was feeding her. The staff member had to pull her over to help the resident to sit upright in the wheelchair since Resident #26 continued to slump over to her left side. Observation on 4/15/2025 at 8:32 AM, the staff member continued to prop Resident #26 up for her to sit upright in his wheelchair. A telephone call was placed to the Pharmacist on 4/16/2025 at 12:09 PM. No return call was received from the Pharmacist prior to exiting the facility. During an interview on 4/16/2025 at 12:15 PM, the Director of Nursing (DON) was asked about Resident #26's prn Lorazepam order. The DON stated, .her Lorazepam is prn and it should not be ordered no longer than 14 days. Yes, it has been ordered since 1/2025 .all prn antianxiety meds should have a stop date of 14 days .I usually go in and check for this, but I missed it .we do discuss this with the hospice agency and they know our process for ordering these medications for only 14 days prn .

**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 accommodate dietary preferences for 2 of 2 (Resident #33 and #42) sampled residents reviewed for dietary preferences. The findings include: 1. Review of the undated facility policy titled, RESIDENT FOOD PREFERENCES, revealed .Food preferences will be honored unless contraindicated .The facility will offer residents food choices and preferences to include .personal preferences .The Food Service Manager or designee will interview the resident and obtain their food preferences .Food preferences will be updated accordingly and will be noted in the resident's tray card .The staff may follow the list of resident's food choices and preferences . 2. Review of the medical record revealed Resident #33 was admitted on [DATE], with diagnoses which included Muscle Wasting and Atrophy, Chronic Pain Syndrome, Need for assistance with personal care, and Anorexia. Review of the Nutritional Risk Quarterly Review dated 6/17/2024, revealed no discussion with Resident #33 related to his food preferences. Review of the Nutritional Risk Quarterly Review dated 9/11/2024, revealed no discussion with Resident #33 related to his food preferences. Review of the Nutritional Risk Quarterly Review dated 12/4/2024, revealed no discussion with Resident #33 related to his food preferences. Review of the Nutritional assessment dated [DATE], revealed food preferences for French toast and pancakes. Continue review revealed .List any Food/Beverage Dislikes See Tray Card . Review of the Annual Minimum Data Set assessment (MDS) dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review revealed Resident #33 required setup or clean-up assistance with eating. Further review revealed Resident #33 had no significant weight loss in the last month or 6 months. Review of the current comprehensive care plan revealed, .My history indicates that I have experienced serious trauma during my lifetime. Specifically, trauma related to .Homelessness, living through depravation, going without food . Review of Resident #33's printed tray card dated 4/15/2024 revealed no area for likes or dislikes. During an interview on 4/14/2025 at 9:15 AM, Resident #33 was asked if breakfast was good. Resident #33 stated, .I haven't seen a good breakfast, pancakes and french toast is what I like but oatmeal is what I got . Observation in the dining room on 4/15/25 07:49 AM, residents were noted to have pancakes on their breakfast tray. During an interview on 4/15/25 at 8:36 AM, Resident #33 was asked how his breakfast was this am. Resident #33 stated, .got to go with what they cook .just take what you can get . Resident #33 had eaten his eggs and half of his oatmeal. 3. Review of the medical record revealed Resident #42 admitted to the facility on [DATE], with diagnoses which included Rhabdomyolysis, Dementia, Essential Hypertension, and Dehydration. Review of Resident #42's admission Progress Note dated 2/27/2025 revealed, .The resident has a good appetite but does not like to drink tea . Review of the admission MDS dated [DATE], revealed Resident #42 had a BIMS score of 8 which indicated moderate cognitive impairment. Continued review revealed Resident #42 required setup or clean-up assistance with eating. Further review revealed Resident #42 had weight loss noted prior to his admission. Review of the current comprehensive care plan revealed, .At possible risk for dehydration with signs and symptoms R/T [related to]: history of dehydration poor po [by mouth] intake at times . Review of Resident #42's Nutritional assessment dated [DATE] revealed the Food Preferences were not marked, list of food/beverage dislikes was blank, and comments related to food preferences noted .See tray card . Further review revealed RD [Registered Dietician] Summary noted Resident #42 remains at risk for compromise in nutrition and hydration status related to altered nutrition related lab values and being on meds that may have nutritionally significant side effects. Observation on 4/14/2025 at 12:14 PM, Resident #42 was noted to have tea on his tray. Continued review revealed Resident #42 had eaten 100% (percent) of his meal and had not touched his tea. Review of Resident #42's printed tray card dated 4/15/2024 revealed no area for likes or dislikes. During an interview on 4/15/2025 at 3:10 PM, the Dietary Manager was asked about the 3/6/2025 Nutritional Assessment being blank for beverage dislikes. The Dietary Manager stated, .I don't do the preferences in [Named Computer system], I don't have access to it .I do them on paper . The Dietary Manager searches through her filed papers and stated, .I haven't done a preference on him. I usually do it when they admit .No he shouldn't have received tea on his tray . During an interview on 4/15/2025 at 3:15 PM, the Dietary Manager was asked if Resident #33's food preferences noted he enjoyed pancakes and french toast should he receive those foods at breakfast. The Dietary Manager stated, .he never has said he wanted them daily . The Dietary Manager was asked to show this surveyor his tray card. Review of the tray card with the Dietary Manager revealed no likes or dislikes noted on the tray card. The Dietary Manager stated, .It's not going to show the likes and dislikes . The Dietary Manager was asked if staff prepare the trays by the review of the tray cards. She stated, yes. The Dietary Manager and Regional Dietary Manager was asked how the staff members who prepare the trays on the tray line would know what foods the resident prefers. The Dietary Manager stated, .I see what you are saying but the Certified Nursing Assistants would come back and get something else if they didn't like it .If he liked pancakes, he should receive them when we have them . During an interview on 4/15/2025 at 4:00 PM, the Administrator was asked if the food preference policy should be followed. She stated, Yes, it should be followed. The Administrator was shown Resident #33 and Resident #42's tray card which revealed no likes or dislikes. The Administrator stated, .usually tray cards show the likes and dislikes I will have to check with [Named Dietary Company] to see why the cards are not showing that .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observations and interviews the facility failed to ensure staff followed hand hygiene guidelines during wound care for 1 of 1 (Resident #13) reviewed for wound care. The findings include: 1. Review of the facility policy titled, Dressing Change, Clean, dated 1/1/2024, revealed .Procedure Purpose .To prevent infection and spread of infection .Perform hand hygiene .put on .disposable gloves .Cleanse wound .Apply prescribed medication .Apply dressings .Remove gloves .Wash hands . 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Muscle Weakness, Abnormal Posture, Hemiplegia and Hemiparesis, and Low Back Pain. Review of Care Plan dated 1/28/2025, revealed .Skin .has disruption of skin surface .to labia .disruption of skin surface will remain free from infection . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated that Resident #13 was severely cognitively impaired. Review of the Physician's orders dated 3/13/2025, revealed .Clean sacrum with wound cleanser. Pat dry. Apply zinc oxide paste and apply non pressure dressing to sacrum daily and PRN [as needed]. every day shift for pressure injury healing AND every 12 hours as needed for pressure injury healing . Review of the Physician's orders date 4/15/2025, revealed .Apply layer of Dermaphor to right labia Q [every] shift and PRN every shift for protection AND as needed for protection . During observation in Resident #13's room on 4/16/2025 at 9:22 AM, revealed Licensed Practical Nurse (LPN) D touched the paper towel dispenser after washing hands, then preceded to resident's bedside to begin wound treatment. LPN D reached into uniform pocket with gloved hand to retrieve a marker, used the marker on clean dressing, and laid marker on bedside table without a barrier, applied dressing to sacral wound, changed gloves and then preceded to address the next wound. LPN D removed the marker from bedside table and placed into uniform pocket, then exited the resident's room and applied Alcohol Based Hand Rub (ABHR) to hands. LPN D failed to perform proper hand hygiene after touching paper towel dispenser, after reaching in pocket, between wound care treatments, and after completing all wound care. LPN D failed to sanitize marker prior to exiting room to prevent cross contamination. During an interview on 4/16/2025 at 11:27 AM, LPN D confirmed that staff should not touch the paper towel dispenser after washing hands, staff should not reach into uniform pocket with gloved hand, proper hand hygiene should be performed between wounds, and multiuse items should be sanitized after use. During an interview on 4/16/2025 at 11:53 AM, the Director of Nursing (DON) confirmed that staff should not touch the paper towel dispenser after washing hands, staff should not reach into uniform pocket with gloved hand, proper hand hygiene should be performed between wounds and at end of wound care treatment, and multiuse items should be sanitized after use.

Based on facility document review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when 1 of 1 ice machine was observed to have a dark slimy buildup on the inner seal. The census was 46 with 44 residents receiving a tray from the kitchen. The findings: 1. Review of the undated, facility document titled, Physical Plant-Monthly Inspections, revealed .Ice Machines: Clean filters and check water filter and observe for proper operation. Look for any calcium, lime, or algae. Check to ensure it is in a clean and sanitized state. This includes all ice machines throughout the facility including Dietary . 2. Observation and interview on 4/14/2025 at 8:44 AM, with the Dietary Manager (DM) revealed the ice machine had a black, slimy substance all around the inside seal. The DM was asked who was responsible for cleaning the ice machine. The DM stated, Maintenance. The DM was asked if it was clean. The DM stated, No. Observation and interview on 4/15/2025 at 8:38 AM, with the DM revealed the ice machine had a black, slimy substance all around the inside sea. The DM was asked if the ice machine had been cleaned. The DM stated, I told maintenance, and he must not have cleaned it. The DM stated that she would tell him again and we could come back to check it later. During an interview on 4/15/2025 at 4:15 PM, the Regional Dietary Manager (RDM) was asked who was responsible for cleaning the ice machine. The RDM stated, Maintenance. The RDM was asked who is ultimately responsible for the ice machine. The RDM stated kitchen . During an interview on 4/15/2025 at 5:06 PM, the Administrator was asked if there should be black slime on the ice machine. The Administrator stated, Absolutely not.

**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 formulate an Advance Directive to residents or the residents' responsible parties for 3 of 16 sampled residents (Resident #13, #17, and #35) reviewed for Advanced Directives. The findings include: Review of the facility's policy titled, Advance Directives Policy and Procedure, dated 1/1/2017, revealed .The facility provides the resident's the right to accept or refuse medical and surgical treatment, and at the resident's option, formulate an advance directive .Determine upon admission whether the resident/legal representative has an advanced directive and if not, determine whether the resident/legal representative wishes to formulate an advance directive .Upon admission, the facility will provide written information to resident/legal representative concerning the resident's rights to make decisions regarding medical care including the right to accept/refuse medical treatment and the right to formulate advance directives .the facility must determine if the resident executed an advance directive or has given other instructions to indicate what care is desired in case of subsequent incapacity .If the resident has not executed advance directives or is incapacitated, the facility will advise the resident/legal representative regarding the right to establish an advance directive . Review of the medical record, revealed Resident #13 was admitted to the facility on [DATE] with diagnoses of Aphasia, Dementia, Diabetes, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 had a Brief Interview For Mental Status (BIMS) of 3, which indicated severe cognitive impairment. Review of Resident #13's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Aphasia, and Schizoaffective Disorder. Review of the significant change MDS assessment dated [DATE], revealed Resident #17 had a BIMS of 12, which indicated moderate cognitive impairment. Review of Resident 17's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. Review of the medical record, revealed Resident #35 was admitted on [DATE] with diagnoses of Diabetes, Seizures, Anxiety, and Dysphagia. Review of the annual MDS assessment dated [DATE], revealed Resident #35 had a BIMS score of 0, which indicated severe cognitive impairment. Review of Resident #35's medical record, revealed there was no documentation the resident or their legal guardian were informed or provided written information regarding their right to formulate an Advanced Directive upon admission. During an interview on 8/2/2022 at 8:29 AM, the Administrator confirmed the facility was unable provide documentation that Resident #13, #17, and #35 or their responsible parties were given a right to formulate an Advance Directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to ensure Physician Orders were followed for notification to the Physician for 1 of 6 sampled residents (Resident #26) reviewed for unnecessary medication. The findings include: Review of the facility's undated policy titled, PHYSICIANS ORDERS-(FOLLOWING PHYSICIAN ORDERS), revealed .It is the policy of the facility to follow the orders of the physician . Review of the facility's undated policy titled, BLOOD GLUCOSE MONITORING, revealed .Blood sugars found to be below 70 or above 400 will be reported immediately to the physician and resident's representative . Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Diabetes, Heart Failure, and Anxiety. Review of the Physician Orders dated 7/3/2022, revealed .Insulin Lispro Solution 100 UNIT/ML [milliliters] Inject as per sliding scale .If BS [Blood Sugar] 60 or > [greater than] 400 notify MD/NP [Medical Doctor/Nurse Practitioner] .TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Review of the Care Plan dated 7/12/2022, revealed, .Potential for signs of hypo/hyperglycemia [decreased/increased blood sugar] related to diagnosis of diabetes .Observe for signs of hypoglycemia .pallor, diaphoresis, shakiness, change in mental status .assess blood sugar via [by way of] accucheck [blood glucose monitoring] and notify physician if abnormal . Review of the Progress Notes dated 7/31/2022, revealed .Resident is alert and able to make needs known. Resident has been up and propelling self in wheelchair . During an interview on 8/1/2022 at 3:42 PM, revealed Resident #26 confirmed last week his blood sugar was 430, he received 12 units of insulin and his blood glucose dropped to 50 during the night. Review of the Nurses' Progress Notes dated 7/27/2022, revealed .Resident wife called voicing concerns regarding HS [hour of sleep] insulin of 25 units and ssi [Sliding Scale Insulin] for BS over 400. This nurse explained that insulin was given per orders and MD [Medical Doctor] was aware . There was no documentation on 7/27/2022 of the hypoglycemic episode. During an interview on 8/2/2022 at 3:15 PM, the Director of Nursing (DON) and Registered Nurse (RN) #1 confirmed Resident #26's blood glucose was 50 on 7/27/2022, and LPN #2 failed to document, notify the physician, and follow the facility policy, and a one on one in-service was done with LPN #2 today. During a telephone interview on 8/3/2022 at 11:00 AM, LPN #2 confirmed she was working on 7/26/2022 and Resident #26's blood sugar was 50. LPN #2 confirmed she did not document in his chart and failed to notify the doctor that his blood sugar had dropped to 50.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure physician orders were followed for 1 of 5 (Resident #25) sampled residents reviewed for unnecessary medications. The findings include: Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Acquired Absence of Right Leg, Diabetes, Anemia, Bipolar Disorder, History of Malignant Neoplasm of Cervix, Hypertension, Long Term Use of Insulin, Anxiety Disorder, Post Traumatic Stress Disorder, Major Depressive Disorder, and Long Term Use of Anticoagulants. The September 2019 Physician's Orders documented, .HUMULIN R 100 U [units] /1 ML [milliliter] SOLUTION (Insulin Human Regular) units Injection Before meals and Bedtime .0-200=0, 201-250=2u, 251-300=4u, 301-350=6u, 351-400=8 [u], > [greater than] 400 call MD [Medical Doctor] . The September 2019 Medication Administration Record (MAR) documented a blood glucose level of 486 on 9/17/19 and the MD was not notified. Interview with the Regional Nurse Consultant on 10/10/19 at 9:25 AM, at the 100/200 Hall Nurses' Station, the Regional Nurse Consultant was asked if the doctor had been notified of the blood sugar > 400. The Regional Nurse Consultant confirmed the MD had not been notified of the blood glucose results.

**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 accurate documentation related to insulin administration for 1 of 5 (Resident #25) sampled residents reviewed for unnecessary medications and failed to ensure medical information was kept private and confidential for 1 of 13 (Resident #24) sampled residents. The findings include: 1. The facility's Medication Administration Subcutaneous Insulin policy, reviewed 1/14 documented, .Check prescriber's order for insulin .Determine the correct amount of insulin to be withdrawn . 2. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses of Acquired Absence of Right Leg, Diabetes, Anemia, Bipolar Disorder, History of Malignant Neoplasm of Cervix, Chronic Obstructive Pulmonary Disease, Hypertension, Long Term Use of Insulin, Anxiety Disorder, Post Traumatic Stress Disorder, Major Depressive Disorder, and Long Term Use of Anticoagulants. The September 2019 Physician's Orders documented, .HUMULIN R 100 U [units] /1 ML [milliliter] SOLUTION (Insulin Human Regular) units Injection Before meals and Bedtime .0-200=0, 201-250=2u, 251-300=4u, 301-350=6 u, 351-400=8 [u], > [greater than] 400 call MD [Medical Doctor] The Medication Administration Record (MAR) for the month of September 2019 documented the following: a. 9/3/19 at 6:00 AM the blood glucose was 283 and 54 units of insulin was documented as administered. 4 units of insulin was ordered to be administered. b. 9/3/19 at 8:30 PM the blood glucose was 388 and 73 units of insulin was documented as administered. 8 units of insulin should have been administered. c. 9/4/19 at 6:00 AM the blood glucose was 284 and 54 units of insulin was documented as administered. 4 units of insulin was ordered to be administered. d. 9/4/19 at 8:30 PM the blood glucose was 378 and 12 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. e. 9/9/18 at 6:00 AM the blood glucose was 194 and 65 units of insulin was documented as administered. Resident #25 should not have received any insulin. f. 9/12/19 at 8:30 PM the blood glucose was 390 and 73 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. g. 9/1719 at 8:30 PM the blood glucose was 486 and 73 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. h. 9/18/19 at 8:30 PM the blood glucose was 367 and 6 units of insulin was documented as administered. 8 units of insulin was ordered to be administered. The September 2019 Physician's Orders documented, .9/19/19 .LANTUS U/1 ML Solution (Insulin Glargine, Recombinant) 70 units Subcutaneous Twice a day 09:00 [9 AM], 21:00 [9 PM] . There was no documentation on the Medication Record (MAR) the insulin was administered on 9/28/19 at 9:00 PM and on 9/29/19 at 9:00 AM. Interview with Regional Nurse Consultant and the Informatics Nurse on 10/10/19 at 9:35 AM, at the 100/200 Hall Nurses' Station, the Regional Nurse Consultant confirmed the inaccurate documentation of the insulin administered. The Informatics Nurse stated, I feel it is a data entry issue. The Regional Nurse Consultant confirmed his statement. The Regional Nurse Consultant was asked about the documentation of the Lantus insulin. The Regional Nurse Consultant confirmed the Lantus insulin was not documented as ordered on the MAR. 3. The facility's HIPAA [Health Insurance Portability and Accountability Act] - General policy, revised 5/14 documented, .It shall be the policy of the facility to protect and safeguard the protected health information (PHI) created . Random observations on the 300 Hall outside the Janitor's Closet on 10/8/19 at 4:02 PM, revealed Resident #24's Electronic Health Record (EHR) was open, with personal information that included her medication administration record displayed on the screen, in public view. No staff were present. Interview with Licensed Practical Nurse (LPN) #1 on 10/8/19 at 4:08 PM, on the 300 Hall by the Janitor's Closet, LPN #1 was asked if personal information on the EHR was left in view of the public. LPN #1 confirmed the EHR was open to the public and stated, .No .it should have been closed down. Interview with the Director of Nursing (DON) on 10/10/19 at 12:11 PM, in the DON office, the DON was asked if the resident's EHR should be left opened and unattended on the computer in public view. The DON stated, No.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to document treatments and provide treatment orders for pressure ulcers for 2 of 3 (Resident #3 and #27) sampled residents reviewed with pressure ulcers. The findings include: 1. The facility's Wound Prevention and Management Program policy, revised 5/17 documented, .To identify Residents at risk of developing pressure ulcers and conduct appropriate interventions to maintain intact skin .Write a separate treatment order for each wound site .D. MANAGEMENT OF WOUND INFECTION: The purpose of this procedure is to prevent wound deterioration, and other complications .provide local management that optimizes healing potential . 2. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Obesity, Polyneuropathy, Osteoarthritis, Dementia, Bipolar Disorder, Anxiety Disorder, Hypertension, and Heart Failure. The Comprehensive Care Plan dated 7/24/19 documented, .I am at risk for skin breakdown .non-compliance with being off load at times .choosing not to receive incontinence care at times .I have areas of skin breakdown now on my buttocks .Please treat areas of my skin that are broken down according to my doctors [doctor's] orders . A Physician's Order dated 6/3/19 documented, .Site: left buttock / Topical Every Shift [day shift 7 AM-7 PM, night shift 7 PM-7AM] .Treatment: Clean with W/C [wound cleanser], apply skin prep, and leave OTA [open to air] . Review of the June 2019 Treatment Administration Record (TAR) revealed there was no treatment documented for the night shift on 6/20/19. A Physician's Order dated 6/21/19 documented, .Site: left buttock / Topical Every Shift .Treatment: Clean with W/C, air dry, skin prep around wound, and cover with moisture-balancing dressing . Review of the June 2019 TAR revealed there was no treatment documented for the night shift on 6/23/19. Review of the July 2019 TAR revealed there was no treatment documented for the night shift on 7/2/19, 7/3/19, 7/7/19, 7/16/19, and on both shifts on 7/20/19. A Physician's Order dated 8/30/19 documented, .Site: left buttocks .day shift .clean w/ [with] W/C, apply skin prep to intact peri-wound, and cover wound-bed with hydrogel dressing . A Physician's Order dated 9/23/19 documented, .Site: left buttocks every Night and Day Shift .apply skin prep and leave OTA . Review of the September 2019 TAR revealed there was no treatment documented on 9/4/19 and 9/13/19, and no treatment documented for the night shift on 9/24/19. A Physician's Order dated 9/29/19 documented, .Site: left buttocks .Day Shift .apply skin prep and leave OTA . Review of the October 2019 TAR revealed there was no treatment documented on 10/3/19. Observations in Resident #3's room on 10/7/19 at 2:07 PM, revealed Resident #3 had a Stage 2 pressure ulcer to the left buttock, the wound bed was 0.5 centimeters (cm) length (L), 1.3 cm width (W), and less than 0.1 cm depth (D). Interview with the Director of Nursing (DON) on 10/10/19 at 9:03 AM, in the DON office, the DON was asked if there was documentation the pressure ulcer treatments were performed as ordered on 6/20/19, 6/23/19, 7/2/19, 7/3/19, 7/7/19, 7/16/19, 7/20/19, 9/4/19, 9/13/19, 9/24/19, and 10/3/19. The DON stated, No . 3. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer, Muscle Weakness, Dysphagia, Abnormal Posture, and Paraplegia. The admission Minimum Data Set (MDS) dated [DATE] documented Resident #27 was cognitively intact, and had (2) stage 4 pressure ulcers upon admission and (4) unstageable pressure ulcers upon admission. The Care Plan dated 8/28/19 documented, .I am at risk for skin breakdown related to my history of wounds, decreased mobility, current wounds, paraplegia status and protein-calorie malnutrition .with interventions .treat any areas that breakdown according to my doctors [doctor's] orders .9/19/19 Podus boots bilaterally while in bed as allows . Review of the facility's WEEKLY PRESSURE WOUND LOG dated 9/30/19-10/6/19 documented, .Facility Acquired Right pad of foot DTPI [Deep Tissue Pressure Injury] .Size (cm) Lx [by] W 3x1.0 .Depth (cm) 0 .Treatment Apply w [with]/Skin Prep . Review of the facility's WEEKLY PRESSURE WOUND LOG dated 10/7/19-10/13/19 documented, .Facility Acquired Right pad of foot DTPI .Size (cm) LxW 2.5x0.9 .Depth(cm) 0 .Treatment Apply w/Skin Prep . Review of the facility's Week 1 Assessment of the DTPI to the right pad of the foot dated 9/30/19 documented, .Length in cm: 3. Width in cm: 1. Depth in cm: 0 .Physician response: No new orders .Initial assessment . Review of the facility's Week 2 Assessment of the DTPI to the right pad of the foot dated 10/7/19 documented, .Length in cm: 2.5 Width in cm: 0.9 Depth in cm: 0 .Yes .Physician response: No new orders . Medical record review revealed there were no physician's orders for the pressure ulcer to the right pad of the foot. Review of the September and October 2019 TAR, revealed no treatments documented for the right pad of the foot pressure ulcer. Observations in Resident's #27's room on 10/8/19 at 3:06 PM, revealed Resident #27's wound care was performed by RN #1, skin prep was applied to right foot pad DTPI. Interview with the DON on 10/9/19 at 4:42 PM, in room [ROOM NUMBER], the DON was asked if Resident #27 had an order for skin prep to right foot pad. The DON stated, No .