**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 3 of 24 (Resident #6, #17, and #36) residents reviewed for advance directives. The findings include: 1. Review of the facility ' s policy Resident' s Rights Regarding Treatment and Advance Directives dated 7/26/2024, revealed It is the policy of this facility to support and facilitate a resident ' s right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. Advance directive is a written instruction, such as a living will or durable power of attorney for healthcare, recognized under state law relating to the provision of health care when the individual is incapacitated On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Dementia, Cerebral infarction, and Traumatic Brain Injury. Review of the LETTERS OF CONSERVATORSHIP dated 4/18/2011, revealed no documentation of instructions for advance directives. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #6 was severely cognitively impaired. There was no documentation in the medical record if Resident #6 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 3. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Hypertension, Chronic Kidney Disease, and Chronic Obstructive Pulmonary Disease. Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 which indicated Resident #17 was severely cognitively impaired. There was no documentation in the medical record if Resident #17 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 4. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Quadriplegia, Hypertension, and Chronic Kidney Disease. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated Resident #36 was cognitively intact. There was no documentation in the medical record if Resident #36 had an Advance Directive or if the Resident would like to formulate an Advance Directive. 5. During an interview on 9/10/2024 at 1:54 PM, the Administrator confirmed that she was unable to provide any further documentation regarding advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review, and interview, the facility failed to conduct quarterly care conference meetings for 4 of 21 sampled residents (Resident #18, #33, #36, and #54) reviewed. The findings include: 1. Review of the facility's undated policy titled, Care Plans, Comprehensive Person-Centered revealed The IDT [Interdisciplinary Team] includes .the resident and the resident's legal representative .Each resident ' s comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation .including the right to .participate in the planning process .See the care plan and sign it .resident will be informed of his or her right to participate in his or her treatment .The Interdisciplinary Team must review and update the care plan .At least quarterly, in conjunction with the required quarterly MDS assessment .The resident has the right to refuse to participate in the development of his/her care plan and medical nursing treatments. Such refusals will be documented in the resident ' s clinical record . 2. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Dementia, and Anxiety. Review of the Care Conference Report for Resident #18 revealed the last Care Conference was conducted on 12/22/2023. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #18 was cognitively intact. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #18 was cognitively intact. Review of the quarterly MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated Resident #18 was cognitively intact. The facility was unable to provide documentation that a quarterly Care Conference was conducted with the Resident or Responsible Party (RP). 3. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Multiple Sclerosis, Chronic Obstructive Pulmonary Disease and Depression. Review of the Care Conference Report for Resident #33 revealed last Care Conference was conducted on 1/23/2024. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #33 was cognitively intact. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 14, which indicated Resident #33 was cognitively intact. The facility was unable to provide documentation that quarterly Care Conferences were conducted with the Resident or RP. 4. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE], with diagnoses including Quadriplegia, Polyneuropathy, Neuromuscular Dysfunction of Bladder and Chronic Kidney Disease. Review of the Care Conference Report for Resident #36 revealed last Care Conference was conducted on 2/2/2024. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #36 was conatively intact. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #36 was conatively intact. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated Resident #36 was conatively intact. The facility was unable to provide documentation that quarterly Care Conferences were conducted with the Resident or RP. 5. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Dysphagia, and Vascular Dementia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 4, which indicated resident #54 had severe cognitive impairment, was dependent on staff for all care, and was on a mechanical diet. Resident was coded for oxygen and was not receiving any therapy. The facility was unable to provide documentation of quarterly Care Conferences with the Resident ' s RP. 6. During an interview on 9/11/2024 at 4:09 PM the Director of Nursing (DON) stated she was unable to provide quarterly care plan meetings documentation and stated, that is something that we will have to work on .

Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when unlabeled and undated items were found in 2 of 3 (Dogwood Hall and Central) nourishment refrigerators observed. The findings include: 1. The facility's undated policy titled, FOODS BROUGHT IN FROM OUTSIDE SOURCES revealed .When food(s) is brought in from outside sources for the residents .require refrigeration .food items should be labeled with .resident ' s name .date the item(s) was purchased or prepared .and the name of the item . The facility ' s undated policy titled, Refrigerator Food Storage Policy Summary .Labeling & Dating . revealed .Before putting anything in the refrigerator, please ensure the food is in a tightly sealed container and there is a label and date on the product with the resident ' s name and current date . 2. Observation in the Dogwood Hall Nutrition Refrigerator on 9/11/2024 at 12:15 PM and 3:15 PM, revealed an open unlabeled and undated bag of radishes. 3. Observation in the Central Nutrition Refrigerator on 9/11/2024 at 12:21 PM and 3:19 PM, revealed a bag containing undated food. 4. During an interview on 09/11/24 03:22 PM, the Registered Dietician confirmed all items in the nutritional refrigerators should be labeled and dated.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure practices were followed to prevent the potential spread of infection during medication administration when 1 of 4 nurses (Licensed Practical Nurse (LPN) #1) allowed the tip of the eye drop applicator to touch the top of the eyelid for 1 of 4 residents (Resident #221) during medication administration. The findings include: 1. The facility's policy titled, Instillation of Eye Drops, revised 1/2014 documented, .Do not touch the eye or eyelid with the dropper . Review of the medical record, showed Resident #221 had diagnoses of Parkinson's Disease, Anxiety Disorder, Cognitive Communication Deficit, and Dementia. Review of the Physician's Orders dated 3/10/2020, showed, .Tobramycin 0.3% [sign for percent] Eye Drops .Both Eyes Daily for Chronic Conjunctivitis . Observation in the resident's room on 3/17/2020 at 8:46 AM, showed LPN #1 administered one eyedrop into Resident #221's right eye, and touched the top of the right eyelid with the tip of the applicator. LPN #1 administered one eyedrop into Resident #221's left eye, and touched the tip of the applicator to the top of the left eyelid. LPN #1 recapped the medication, placed the medication back into the medication cart, and failed to clean the tip of the applicator. During an interview conducted on 3/17/2020 at 10:03 AM, the Director of Nursing (DON) was asked should nursing staff touch the top of the eyelid with the tip of the applicator when administering eye drops. The DON stated, No, ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to ensure medications were stored properly in 3 of 8 medication storage areas (Palm Medication Cart, Dogwood Medication Cart, and the Supply Room). The findings include: Review of the facility's policy titled, Storage of Medication, revised [DATE], showed that discontinued and outdated medications should be returned to the dispensing pharmacy or destroyed. Observation of the Palm Medication Cart on [DATE] at 11:20 AM, showed the following: a. 1 bottle of Humalog insulin with an open date of [DATE] b. 2 open and undated bottles of Morphine Sulfate. c. 1 bottle of Morphine Sulfate with an open date of [DATE] Observation of the Dogwood Medication Cart on [DATE] at 12:16 PM, showed 4 open and undated bottles of Nitroglycerin sublingual tablets. Observation in the Supply Room on [DATE] at 7:37 AM, showed: a. 1 bottle of stomahesive with an expiration date of 8/2019 b. 1 bottle of Optimum multi-vites (vitamin) liquid with an expiration date of 7/2019 c. 2 bottles of iodoform packing strips (medicated wound dressing) with an expiration date of 8/2019 d. 3 bottles of liquid docusate sodium with an expiration date of 10/2019 e. 2 bottles of liquid docusate sodium with an expiration date of 12/2019 During an interview conducted on [DATE] at 7:57 AM, the Director of Nursing (DON) confirmed that there should not be expired, opened, or undated medications in the medication storage areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer for 1 of 3 (Resident #36) sampled residents reviewed for transfer/discharge requirements. The findings include: 1. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Hypothyroidism, Chronic Kidney Disease, Anxiety, Dementia and Dysphagia. The Interdisciplinary Notes dated 11/8/18 documented, .Skin tear noted to right calf with some heavy bleeding. Pressure applied .EMS [Emergency Medical Services] called and pt [patient] transfer to .ER [Emergency Room] for further eval [evaluation] . The facility was unable to provide documentation that the Ombudsman had been notified of the resident's transfer to the emergency room on [DATE]. Interview with the Administrator on 3/26/19 at 5:24 PM in the Activity Room, the Administrator was asked if Resident #36 should have been on the transfer list. The Administrator confirmed that Resident#36 should have been on the transfer form sent to the Ombudsman.