**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and interview the facility failed to provide information to the residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive for 8 of 24 (Resident #1, #2, #4, #11, #13, #20, #22, and #47) residents reviewed for Advance Directives. The findings include: 1. Review of the facility policy titled, Guidelines for Resident Rights-Advanced Directive(s), dated 6/4/2024, revealed Residents have specific rights related to advance directives .The facility must ensure that these rights are explained, documented . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Chronic Atrial Fibrillation and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated Resident #1 was moderately cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 3/30/2023, revealed the document was not filled out completely or correctly. 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hemiplegia, Aphasia, Tracheostomy, Cerebral Infarction, Atrial Fibrillation, Diabetes, and Anxiety. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 2, which indicated Resident #2 was severely cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 10/1/2024, revealed the document was not filled out completely or correctly. 4. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, Heart Failure, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 12, which indicated Resident #4 was moderately cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 10/3/2024, revealed the document was not filled out completely or correctly. 5. Review of medical record revealed Resident #11 was admitted on [DATE], with diagnoses that included Diabetes, Paranoid Schizophrenia, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated Resident #11 was severely cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 9/19/2024, revealed the document was not filled out completely or correctly. 6. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with diagnoses including Hypertension, Heart Failure, Chronic Kidney Disease, and Atrial Fibrillation. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated Resident #13 was severely cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 9/24/2024, revealed the document was not filled out completely or correctly. 7. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypertension, Schizophrenia, and Cardiomyopathy. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 3 which indicated Resident #20 was severely cognitively impaired. Review of the facility document titled, Acknowledgement of Advanced Directive Discussion, dated 10/22/2024, revealed the document was not filled out completely or correctly. 8. Review of medical record revealed Resident #22 was admitted on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Hypertensive Chronic Kidney Disease, Dementia, and End Stage Renal Disease. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 3, which indicated Resident #22 was severely cognitively impaired. Review of the facility document, Acknowledgement of Advanced Directive Discussion, dated 11/19/2024, revealed the document was not filled out completely or correctly. 9. Review of medical record revealed Resident #47 was admitted on [DATE], with diagnoses including Anxiety, Depression, and Rheumatoid Arthritis. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13 which indicated Resident #47 was cognitively intact. Review of the facility document titled, Acknowledgement of Advance Directive Discussion, dated 9/5/2024, revealed the document was not filled out completely or correctly. 10. During an interview on 1/29/2025 at 10:57 AM, the Admissions Director confirmed that the facility Acknowledgement of Advance Directive Discussion form was not filled out correctly on admissions. The Admissions Director confirmed that if a resident had a cognitive deficit, she was not aware the responsible party should have filled out the advance directive form. During an interview on 1/29/2025 at 11:08 AM, the Director of Social Services confirmed that the facility Acknowledgement of Advance Directive Discussion form was not correctly filled out. She confirmed that the Responsible Party should have been notified to fill out the form if resident was unable due to cognitive deficits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure behavior monitoring and side effects of psychoactive medications were monitored for 1 of 5 sampled residents (Resident #256) reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, .Psychotropic Medication . dated 8/18/2023, revealed .Psychoactive medications include .anti-psychotic and anti-depressants .Monitors psychotropic drug use daily noting any adverse side effects .Monitors for presence of target behaviors on a daily basis . 2. Review of the medical record review revealed Resident #256 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Psychosis, Dementia, and Diabetes. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #256 received an anti-psychotic and anti-depressant medication 7 days of the review period. Review of the Order Summary Report dated 1/16/2025, revealed SEROquel (an anti-psychotic medication) oral tab .12.5mg (milligram) .one time a day . Review of the Order Summary Report dated 1/16/2025, revealed SEROquel .oral tab .12.5 mg . in the afternoon . Review of the Order Summary Report dated 1/16/2025, revealed SEROquel .oral tab .25mg .at bedtime . Review of the Order Summary Report dated 1/23/2025, revealed Lexapro (an anti-depressant) .5 mg .one time a day . Review of the medical record revealed the anti-psychotic and the anti-depressant medications were not monitored for behaviors or side effects. During an interview on 1/30/2025 at 1:05 PM, The Director of Nurses (DON) confirmed there were no orders for behavior or side effect monitoring for the antipsychotic and psychotropic medications that Resident #256 was receiving. The DON confirmed the facility should be monitoring these medications daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observations, and interview, the facility failed to minimize the potential for foodborne illness transmission by not properly monitoring temperatures for 2 of 46 (Resident #10 and Resident #27) personal refrigerators located in resident rooms. The findings included: 1. Review of the undated facility policy titled, Refrigerator/Freezer Temperatures, revealed .in order to ensure all perishable food stuff stays fresh and palatable, temperatures will be recorded on all refrigerators .Each refrigerator .located outside of the main kitchen (i.e .personal) is checked daily and recorded on Refrigerator .Temperature log by the appropriate department .If the temperature on the internal thermometer is outside of the acceptable range .personal refrigerators are permitted to be kept in a resident's room .Each refrigerator shall have a temperature log with daily entry .Each refrigerator will have an inside thermometer .will be maintained at or below 41 degrees Fahrenheit [F] . 2. Review of the medical records revealed Resident #10 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Atrial and Chronic Kidney Disease. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with diagnoses including Idiopathic Peripheral Neuropathy, Peripheral Vascular Disease and Anorexia. During observation on 1/28/2025 at 10:05 AM and on 1/29/2025 at 12:50 PM, revealed Resident #10's refrigerator was full of food items and no thermometer was visible. During observation on 1/29/2025 at 12:45 PM, revealed Resident #27's refrigerator temperature was 60 degrees. No food items were present. Observation and interview on 1/30/2025 at 1:28 PM, Certified Nursing Assistant (CNA) A was asked to verify Resident #10's refrigerator temperature. CNA A stated, to be honest, there is not even a thermometer in her refrigerator. CNA A was asked if there should be a thermometer in the refrigerator and she responded yes. Observation and interview on 1/30/2025 at 1:34 PM, CNA A was asked to verify Resident #27's refrigerator temperature. CNA A stated the temperature was 45 degrees F. CNA A was asked what the temperature should be, and she stated, the temperature should be less than 41 degrees F. CNA A was then asked what should be done next and she confirmed the temperature should be adjusted and the temperature rechecked. CNA A did not discard the food items in the refrigerator. 3. During an interview on 1/30/2025 at 5:15 PM, the Director of Nursing (DON) was asked what staff was responsible for checking the refrigerator temperatures. The DON stated that nursing staff checks the temperatures. The DON was asked what the temperature should the refrigerator temps be and she stated between 35-41 degrees F. The DON was then asked what should be done if the refrigerator temperature was out of range. The DON stated they are to adjust the temperature and recheck the temperature. If there are food items in the refrigerator, they should be thrown away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to complete a quarterly assessment, using the Centers for Medicare & Medicaid Services-specific RAI process within the regulatory time frames for 2 of 19 (Resident #2 and #5) sampled residents reviewed. The findings include: 1. The MDS 3.0 RAI Manual v (version) 1.16 October 1, 2018 page 2-33 documented, .The Quarterly assessment must be completed at least every 92 days following the previous OBRA [Omnibus Budget Reconciliation Act] assessment of any type .The ARD [Assessment Reference Date] (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type .The MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . 2. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses of Dementia with Behavioral Disturbance, and Depression. Review of the quarterly MDS with an ARD date of 7/3/19 revealed Item Z0500B was not completed. The MDS should have been completed by 7/17/19. Telephone interview with the Regional MDS Coordinator on 9/24/19 at 1:16 PM, the Regional MDS Coordinator was asked if the 7/3/19 MDS for Resident #2 was completed. The Regional MDS Coordinator stated, It is not. The Regional MDS Coordinator was asked if it should have been completed. The Regional MDS Coordinator stated, If it is from July, then yes. 3. Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Neuropathy, Obsessive-Compulsive Personality Disorder, and Adult Failure to Thrive. Review of the quarterly MDS with an ARD date of 8/2/19 revealed Item Z0500B was not completed. The MDS should have been completed by 8/16/19. Telephone interview with the Regional MDS Coordinator on 9/24/19 at 1:16 PM, the Regional MDS Coordinator was asked if the 8/2/19 MDS for Resident #5 was completed. The Regional MDS Coordinator stated, It is not. The Regional MDS Coordinator was asked if it should have been completed. The Regional MDS Coordinator stated, If that was the ARD date, then, yes it should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH Edition provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Registered Nurse (RN) #1) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 3 errors were observed out of 29 opportunities, resulting in an error rate of 10.34482759% The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS . Novolog .Insulin . Aspart . Rapid-Acting Insulin .ONSET .15 min . ADMINISTRATION/COMMENTS .5-10 minutes prior to meals . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Cerebral Infarction, Chronic Kidney Disease and Hypertension. The physician's orders dated 4/3/19 documented, NovoLOG Solution 100 UNIT/ML [milliliters] (Insulin Aspart) Inject as per sliding scale .200-249 = 5 [units] .300-349 = 10 [units] .subcutaneously before meals . Observations in Resident's #18's room on 9/23/19 at 11:33 AM, revealed Registered Nurse (RN) #1 administered Novolog 10 units subcutaneously to Resident #18 for a blood glucose level of 337. A meal or substantial snack was not offered to Resident #18 until a meal tray was delivered at 12:30 PM, which was 57 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolog resulted in medication administration error #1. Observations in Resident #18's room on 9/23/19 at 5:10 PM, revealed RN #1 administered Novolog 5 units subcutaneously to Resident #18 for a blood glucose level of 213. A meal or substantial snack was not offered to Resident #18 until the RN provided Resident #18 with a supplement at 5:53 PM, which was 43 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolog resulted in medication administration error #2. 3. Medical record review revealed Resident #24 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, End Stage Renal Disease, Heart Disease and Hypertension. The physician's orders dated 8/11/19 documented, NovoLOG Solution 100 UNIT/ML (Insulin Aspart) Inject 5 unit subcutaneously before meals . Observations in Resident #24's room on 9/23/19 at 4:53 PM, revealed RN #1 administered Novolog 5 units subcutaneously to Resident #24. A meal or substantial snack was not offered to Resident #24 until a meal tray was delivered at 5:21 PM, which was 28 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolg resulted in medication administration error #3. Interview with the Director of Nursing (DON) on 9/23/19 at 5:24 PM, in the DON Office, The DON was asked when should a resident receive a substantial snack or meal after receiving Novolog insulin. The DON confirmed the resident should have received a meal or snack within 5-10 minutes of insulin administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 3 (Registered Nurse (RN) #1) nurses administered medications free of significant medication errors. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, 11TH edition provided by the American Society of Consultant Pharmacists documented, .DIABETES: INJECTABLE MEDICATIONS . Novolog .Insulin .Aspart .Rapid-Acting Insulin .ONSET .15 min .ADMINISTRATION/COMMENTS .5-10 minutes prior to meals . 2. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Cerebral Infarction, Chronic Kidney Disease and Hypertension. The physician's orders dated 4/3/19 documented, NovoLOG Solution 100 UNIT/ML [milliliters](Insulin Aspart) Inject as per sliding scale .200-249=5 [units] .300-349 =10 [units] .subcutaneously before meals . Observations in Resident's #18's room on 9/23/19 at 11:33 AM, revealed Registered Nurse (RN) #1 administered Novolog 10 units subcutaneously to Resident #18 for a blood glucose level of 337. A meal or substantial snack was not offered until a meal tray was delivered to Resident #18 at 12:30 PM, which was 57 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolog resulted in a significant medication error. Observations in Resident #18's room on 9/23/19 at 5:10 PM, revealed RN #1 administered Novolog 5 units subcutaneously to Resident #18 for a blood glucose level of 213. A meal or substantial snack was not offered until the RN provided Resident #18 with a supplement at 5:53 PM, which was 43 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolog resulted in a significant medication error. 3. Medical record review revealed Resident # 24 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, End Stage Renal Disease, Heart Disease and Hypertension. The physician's orders dated 8/11/19 documented, NovoLOG Solution 100 UNIT/ML (Insulin Aspart) Inject 5 unit subcutaneously before meals . Observations in Resident #24's room on 9/23/19 at 4:53 PM, revealed RN #1 administered Novolog 5 units subcutaneously to Resident #24. A meal or substantial snack was not offered until a meal tray was delivered to Resident #24 at 5:21 PM, which was 28 minutes later. The failure of the nurse to provide a meal or substantial snack within 5-10 minutes of administration of the Novolg resulted in a significant medication error. Interview with the Director of Nursing (DON) on 9/23/19 at 5:24 PM, in the DON Office, The DON was asked when should a resident receive a substantial snack or meal after receiving Novolog insulin. The DON confirmed the resident should have received a meal or snack within 5-10 minutes of insulin administration.

**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 practices to prevent the potential spread of infection were maintained for 1 of 2 (Resident #48) sampled residents observed during a dressing change. The findings include: 1. The Lippincott Manual of Nursing Practice, 10th EDITION documented, .Keep the drainage bag in a dependent position, below the level of the bladder . 2. Medical record review revealed Resident #48 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Atrial Fibrillation, Dysphagia, Anxiety, Depression, Sacral Pressure Ulcer, Cerebral Infarction, Chronic Kidney Disease, and Gastrostomy. 3. A Physician's order dated 7/30/19 documented, .Cleanse wound to sacral area with Dakins, pat dry, Apply Calcium Alginate and Collogen dressing to wound bed, cover with ABD [abdominal] pad, secure with border dressing daily every day shift . A Physician's order dated 11/30/18 documented, .May change indwelling silicone silver tip catheter number 18 Fr [french] 30 cc [cubic centimeters] bulb as needed for urinary retention . 4. Observations in Resident #48's room on 9/24/19 at 2:20 PM, revealed Registered Nurse (RN) #1 performed dressing changes with the assistance of Certified Nursing Assistant (CNA) #1 and CNA #2. CNA #1 placed Resident #48's indwelling urinary catheter tubing and bag on the foot of the bed during the dressing change. CNA #1 and #2 changed a blue pad saturated with bloody drainage from the resident's sacral wound by rolling the resident, and placed a clean, dry blue pad under the resident on top of a bed sheet that was saturated with wound drainage. After the dressing change, Resident #48 was positioned in the bed and the bedside drainage bag was positioned back under the bed at 3:03 PM, 35 minutes later. Interview with CNA #1 on 9/24/19 at 3:05 PM, in Resident #48's room, CNA #1 was asked if it was appropriate to leave the catheter bag on the bed during the dressing change. CNA #1 stated, no . Interview with CNA #2 on 9/24/19 at 3:07 PM, in Resident #48's room, CNA #2 was asked if it was appropriate to cover the saturated bed linen with a clean blue pad. CNA #2 stated, .no .we did not have the supplies in the room . Interview with the Director of Nursing (DON) on 9/25/19 at 11:25 AM, in the DON Office, the DON was asked if it was appropriate to place a bedside drainage bag in the bed with a resident during a dressing change. The DON stated, .no ma'am . The DON was asked it was appropriate to replace blue pads over bed linen that was saturated with drainage from a wound. The DON stated, .all of the linens should have been changed .