**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident #28) out of one resident reviewed for dental assessments. Resident #28 was coded incorrectly as being edentulous. The findings included: Observation and interview with Resident #28 was conducted via a Spanish translator on 2/27/2024 at 7:45 AM. The resident was sitting up in bed, preparing for breakfast, using a hearing amplifier device to hear. The resident had natural teeth, missing teeth on the bottom and had bilateral hand contractures. She revealed, she had not seen a dentist in a long time and wanted to see the dentist. Review of the Demographic Face Sheet for Resident #28 documented the resident was admitted on [DATE] with a diagnosis of heart failure, chronic obstructive pulmonary disease, chronic kidney disease, schizophrenia, hearing loss and major depressive disorder. Review of the Minimum Data Set (MDS) Annual Assessment for Resident #28 dated 12/22/2023 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 11 out of 15 indicating mild cognitive impairment and the resident was able to make her needs known. The resident required partial/moderate assistance for eating and dependent assistance for ADLs (Activities of Daily Living), no natural teeth or tooth fragments edentulous and was coded Yes. Review of the Dental Care Plan for Resident #28 documented the following: Focus: Resident with some natural teeth loss. Resident has lower natural teeth (some missing pieces) (written 6/19/2023; reviewed and updated); Goals: Resident will not have any s/s (signs/symptoms) of discomfort/complications related to teeth loss left unmanaged through next review date; Resident will not have any s/s of discomfort/complications related to teeth loss or use of dentures left unmanaged through next review date and Interventions: Dental consult as needed/as per facility protocol; Assist resident with oral care daily as needed; Assess for loose fitting dentures and report as needed. On 2/29/2024 at 8:55 AM, interview with the Social Services Director. She stated, She has some natural teeth. On 2/29/24 at 9:46 AM, interview and record review with Staff A, Registered Nurse (RN) MDS (Minimum Data Set) Coordinator on 2/29/2024 at 9:46 AM. She stated, We had a part time MDS Coordinator who conducted the assessment and the assessment is incorrect. It is a coding error. The resident does have teeth. She is not edentulous. The care plan reflects that she has teeth. We are going to do a modification of the MDS. Record review of the facility's policy titled, Conducting an Accurate Resident Assessment (no written date) documented: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (comprehensive, quarterly, significant change in status); Policy Explanation and Compliance Guidelines: 2) Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths and areas of decline. The assessment will be documented in the medical record. Review of the facility's policy titled, Resident Assessment -RAI (no written date) documented: Policy: This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI); Policy Explanation and Compliance Guidelines: 2) The assessment will include at least the following: k. Dental and nutrition status and 3) The assessment process will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts.

Based on record review and interview the facility failed to ensure the arbitration agreements presented to three residents (Resident number 12, Resident number 52 and Resident number 153) out of three residents reviewed informed residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. There were 105 residents residing in the facility at the time of the survey. The findings included: Record review of the Binding Arbitration Agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents or their representatives to enter into an arbitration agreement, 3) The facility had residents who entered a binding agreement on or after 9/16/2019 and 4) The Admissions Coordinator is responsible for the binding arbitration agreements. Review of the facility Arbitration Agreement documented the following: Resident number 12 signed and dated on 1/10/2024, Resident number 52 signed and dated on 1/18/2024 and Resident number 153 signed and dated on 2/15/2024 failed to show the arbitration agreements allowed the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. On 2/27/2024 at 11:34 AM, interview and record review with the Admissions Coordinator confirmed that the Arbitration Agreement did not document that the binding arbitration agreement allowed the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the privacy for one resident (Resident # 59) out of one resident for privacy as evidenced by, posting a visible sign on the wall of Resident # 59 room disclosing Protective Health Information (PHI). There were ninety- nine residents residing in the facility at the time of this survey. The findings included: Observation completed on 11/28/2022 at 10:26 AM revealed Resident #59 resting in bed. Resident #59 was alert but has some confusion. Observation revealed a paper attached to the wall at the head of the resident's bed with the resident's name and a sign indicating Heart Monitor in Use sign that stated, Please do not unplug unit. Unplug the power cord will prevent the patient's heart from being monitored. Thank you, [ name of diagnostic company]. (photographic evidence obtained). When the charge nurse was asked about the sign, Staff B, Charge Nurse reported that resident has a pacemaker underneath the skin on the left upper chest and there is a memory device plugged to the wall to record and monitor the heart. Charge nurse reported resident use the pacemaker for two years with the purpose of long-term use. On 11/29/22 at 08:38 AM, observed Resident #59 sleeping in bed. Head of bed was elevated. The heart monitor device was plugged inside the wall. The sign related to the heart monitor in use was not on the wall. On 11/30/22 at 02:48 PM, Resident #59 was observed sitting in chair, watching television. The sign related to the heart monitor in use was no longer posted on the wall. Record review of Resident #59 face sheet revealed initial date of admission [DATE]. Diagnoses included but not limited to: Hypertensive heart disease, Myocardial Infarction, Dementia, Coronary Artery Disease, Pacemaker Placement and Cardiomegaly. Record review of Minimum Date Set (MDS) Quarterly assessment dated on 09/04/2022 revealed: Section C- for cognitive pattern documented a Brief Interview of Mental Status (BIMS) score of 3 out 15 indicating Resident #59 is severely cognitive impaired. Section G- for Functional Status indicated total dependence with extensive assistance for Activities of Daily Living (ADL). Review of Resident #59's care plan dated on 05/05/22 revealed: Resident cardiac stability will maintain as evidenced by no shortness of breath, cyanosis, edema, chest pain, stable. Interview with the DON (Director of Nursing) on 12/01/2022 at 3:50 PM revealed that she did not see the sign that was posted on Resident #59' wall at the head of the bed. When this surveyor showed the picture taken during the initial observation of the visible sign indicating: Heart Monitor in Use with Resident #59 name, heart monitor, and diagnostic testing center telephone number to the DON. The DON stated that she was not aware and acknowledged that the sign should not have been posted and that the sign was removed. During the interview the DON added that they are providing education to the staff about resident's privacy. When a resident is admitted with a medical device such as a pacemaker, she ensured that she has provided teaching to full time regular staff for each unit. Therefore, the regular full-time staff would be knowledgeable about their residents' pertinent diagnoses, conditions, and comorbidities. On 12/01/2022 at 4:30 PM, both the ADON (Assistant Director of Nursing) and (Director of Nursing) acknowledged that the sign was disclosing PHI (protective health information). They did not know who posted the sign on the wall. They believed that it was important to protect resident health information and to promote safety to all the residents. Rewiew of the facility's Policy and Procedures on Privacy dated 2016 revealed: Policy: It is the policy of the facility to ensure that resident's privacy is respected. The Procedures of the Policy about privacy are included but not limited to: 1. The resident has a right to be treated with respect 2. Keep residents personal identifying information covered and out of sight.