**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 1 resident (Resident #49) of 71 residents reviewed for dignity. The findings include: Review of the facility policy titled, Resident Rights, revised 8/16/2018, showed .All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility . Resident #49 was admitted on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Bipolar Disorder, Gastro-Esophageal Reflux Disease, Dysphagia, and Schizophrenia. Review of Resident #49's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) assessment score of 0 indicating the resident had severe cognitive impairment. The resident required extensive assistance of one staff member for eating and had received speech therapy 5 days of the last seven days. During an observation on 9/6/2022 at 11:13 AM, showed a sign taped to the wall above Resident #49's bed .When feeding Resident .Small bites/sips .Alternate food and liquid (At least 2 sips of liquid after each bite) .Cue resident to swallow by slight pressure to cheeks, downward motion on her throat, and downward pressure of spoon .Use tongue depressor to remove food from cheeks to the tongue .No straws .Speech . The signage was visible to anyone who entered the resident's room. During interview and observation on 9/7/2022 at 2:20 PM, Licensed Practical Nurse (LPN) #1 confirmed the signage was present over Resident #49's bed and visible to anyone who entered the resident's room. She stated the sign had been placed there by the speech therapist. LPN #1 stated she was unaware if the family gave permission to hang the sign above the bed. During an interview on 9/7/2022 at 2:35 PM, the MDS Coordinator, confirmed there was no documentation the family had requested or agreed to have the sign placed above the bed. During an interview on 9/8/2022 at 9:14 AM, the Director of Nursing (DON) stated resident medical information was not to be visibly posted unless requested by the resident or family due to privacy. She confirmed the sign that had been hung above Resident #49's bed would be visible to anyone who entered the room. The DON confirmed there was no documentation the family had requested the sign to be hung above the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to revise a care plan for 1 resident (#53) of 18 residents reviewed. The findings include: Review of the facility policy titled, Comprehensive Care Plans, last revised [DATE], showed The care plan will include how the facility will assist the resident to meet their needs, goals and preferences .Reflect the resident's expressed wishes regarding care and treatment goals .Care plans are ongoing and revised as information about the resident and the resident's condition change .The care plan should reflect the current status of the resident and be updated with changes in the residents [resident's] status . Resident #53 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm of Tongue, Type 2 Diabetes Mellitus with Unspecified Complications, Hypertension, and Depression. Review of Resident #53's comprehensive care plan updated [DATE], stated .Honor resident?s [resident's] Advanced Directive and/or Code Status [wishes for care in the event the heart or breathing were to stop] . Record review of a Physician Orders for Scope of Treatment (POST) form dated [DATE], revealed the resident's wishes were to receive CPR [cardiopulmonary resuscitation - life-sustaining treatment] if found with no pulse or not breathing. Review of Resident #53's comprehensive care plan updated [DATE], revealed the resident's code status was .Per POST: CPR, full treatment . Review of a Physician's order dated [DATE], showed an order .Code Status: DNR [Do Not Resuscitate] . Review of a POST form dated [DATE], showed .Do Not Attempt Resuscitation (DNR / no CPR) . During an interview on [DATE] at 12:53 PM, with the Minimum Data Set (MDS) Coordinator stated care plans are updated on a quarterly and as needed basis and would be updated if the Code Status changed. MDS Coordinator confirmed Resident #53's care plan had not been revised to reflect the DNR Code Status.

**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 properly store and discard an outdated nebulizer (device used to administer medication in the form of a mist inhaled into the lungs) administration set up (nebulizer tubing and mask) for 1 resident (#59) of 7 residents reviewed for nebulizer therapy of 23 residents sampled. The findings include: Review of the facility policy Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011, revealed .Store .in plastic bag, marked with date and resident's name, between uses .Discard the administration set-up every seven (7) days . Medical record review revealed Resident #59 was admitted to the facility on [DATE] with diagnoses including Heart failure, Atrial fibrillation, and Shortness of breath. Medical record review of the Care Plan dated 6/27/19 revealed .Resident at risk for .SOB [shortness of breath] .Observe for shortness of breath . Medical record review of the Quarterly Minimum data set (MDS) dated [DATE] revealed Resident #59 had modified independence with decision making. Further review revealed the resident had received respiratory therapy. Medical record review of the Physician's Order Report revealed .Start Date .07/03/2019 .solution for nebulization [medication administered by nebulizer] .as needed every 6 hours for shortness of breath . Medical record review of Medications Administration History dated 8/1/19 - 8/19/19 revealed Resident #59 had received solution for nebulization on 8/18/19 at 4:16 AM. Observation of Resident #59 on 8/18/19 at 9:37 AM, in the resident's room, revealed a unstored nebulizer at the bedside with a mask dated 6/26 (6/26/19). Observation of Resident #59 on 8/19/19 at 8:40 AM, in the resident's room, revealed a unstored nebulizer at the bedside with a mask dated 6/26. Interview with Licensed Practical Nurse (LPN) #1 on 8/19/19 at 8:42 AM, in the resident's room, confirmed the date on the nebulizer mask was 6/26/19. Further interview revealed the mask was to be changed weekly. Continued interview confirmed Resident #59 had received nebulized medication with the mask on 8/18/19 at 4:16AM. Interview with the Central Supply Coordinator on 8/19/19 at 8:52 AM, in the conference room, revealed she was responsible for the weekly changing of the nebulizer administration set up and storage bag. Further interview confirmed she had not changed the administration set up and storage bag for Resident #59 weekly. Interview with the Assistant Director of Nursing (ADON) on 8/20/19 at 10:29 AM, in the ADON's office, confirmed the nebulizer administration set was to be changed on 7/3/19,7/10/19, 7/17/19, 7/24/19, 7/31/19, 8/7/19, and 8/14/19. Continued interview confirmed the facility failed to properly store and discard an outdated nebulizer administration set up for Resident #59.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to provide pharmaceutical services to meet the needs of 1 resident (#66) of 38 residents reviewed. The findings include: Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including Dementia with Behaviors and Chronic Obstructive Pulmonary Disease. Medical record review of a physician's order dated 1/31/18 revealed to discontinue the Zoloft (anti-depressant) 75 mg (milligrams) every day and begin Zoloft 50 mg every day. Interview with the Director of Nurses (DON) on 8/15/18 at 10:30 AM, in the conference room, revealed the verbal order was sent to the pharmacy, and entered into the computer system. Review of the Medication Administration Record (MAR) dated 2/1/18 to 2/28/18 revealed Zoloft 50 mg every day was on the MAR. The resident received 50 mg daily from 2/1/18 to 2/15/18. Medical record review of the pharmacy medication reorder form dated 2/16/18 revealed Zoloft 50 mg tablet was reordered. Medical record review of the pharmacy's Change Report (provided to the DON from the pharmacy) dated 2/15/18 revealed a pharmacy technician at the pharmacy changed the Zoloft 50 mg to Zoloft 100 mg every day. Interview with the Pharmacist on 8/15/18 at 10:25 AM, via telephone, revealed a new technician (who is no longer employed with the pharmacy) changed the order to 100 mg Zoloft, filled the 100 mg Zoloft order, and sent it to the facility. At the time of the change the MAR was updated showing Zoloft 100 mg everyday and not the 50 mg as ordered. Further interview confirmed the pharmacy did not dispense the correct dosage of the Zoloft to the facility. Interview with the DON on 8/15/18 at 8:00 AM, in the conference room, confirmed the resident received 4 days (2/17, 2/18, 2/19 and 2/20/2018) of 100 mg of Zoloft and not the 50 mg which was ordered and the pharmacy had not dispensed the correct dose.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to discard expired medical supplies in 1 of 2 medication storage rooms. The findings include: Observation with Registered Nurse (RN) #1 on [DATE] at 9:25 AM, in the North Medication Storage Room, revealed in the left drawer (under the countertop), two 3-way 24 f (French) 30 cc (cubic centimeters) urinary catheters with an expiration date of 2002; one 2-way 20 f, 5cc urinary catheter with an expiration date of 2004; and one 2-way 22 f, 30cc urinary catheter with an expiration date of 02/2017. Observation and interview with RN #1 on [DATE] at 9:28 AM, at the North Nurse's station confirmed the urinary catheters were expired and available for resident use.