**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and a review of the facility policy titled, Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to submit a PASARR Level II for one of two residents (R) (R1) reviewed for a mental illness diagnosis. This deficient practice had the potential to affect the appropriate level of care and services provided for R1. Findings include: A review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, dated 12/19/2022, revealed the Policy stated, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. The Policy Explanation and Compliance section stated, 6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority. 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. Examples include: b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility with diagnoses including, but not limited to, schizophrenia, psychosis not due to a substance or known physiological condition, mood disorder due to known physiological condition, major depressive disorder, and anxiety disorder. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed section A (Identification Information) documented the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, section I (Active Diagnoses) documented schizophrenia, and section O (Special Treatments and Programs) documented R1 did not receive psychological services. A review of the quarterly MDS dated [DATE] revealed section I (Active Diagnoses) documented schizophrenia, and section O (Special Treatments and Programs) documented R1 did not receive psychological services. A review of the EMR revealed a PASRR Level I request dated 12/12/2022 without schizophrenia marked on the form. A further review revealed there was no re-submission for a PASRR Level I after the facility coded schizophrenia on the MDS. In an interview on 8/21/2024 at 1:03 pm, the Social Service Director (SSD) stated all residents were admitted to the facility with a least a PASRR Level I. The SSD further stated she was responsible for checking the admissions for qualifying diagnoses that would potentially trigger a PASRR Level II. She confirmed that R1 did not have PASRR Level II and had been admitted from a hospital. The SSD confirmed that she was aware R1 had a diagnosis of schizophrenia but felt her hallucinations and delusions were stable. The SSD further stated she did not feel R1 needed a referral for psychological services because the issues she was experiencing were normal for her. In an interview on 8/21/2024 at 1:12 pm, Certified Nursing Assistant (CNA) AA revealed R1 had behaviors such as cursing and speaking inappropriately to staff while they were caring for her roommate. She stated these behaviors seem to not have any triggers. In an interview on 8/21/2024 at 1:16 pm, Licensed Practical Nurse (LPN) BB stated R1 didn't always have behaviors but did have mood swings. LPN BB further stated R1 was not aggressive. However, she yelled out and exhibited attention-seeking behaviors. In an interview on 8/21/2024 at 1:28 pm, LPN Unit Manager CC verified R1 had a diagnosis of schizophrenia and stated the resident had episodes of hollering out for no apparent reason. LPN UM CC stated that R1's behaviors have been communicated to the SSD. LPN UM CC further stated she was not involved in the process of requesting PASARR Level II's. In an interview on 8/21/2024 at 1:45 pm, the Director of Nursing (DON) verified that R1 had inappropriate behavioral outbreaks, delusions, and hallucinations. The DON further stated she did not have knowledge of the criteria for PASARR Level II's because the SSD was solely responsible for that process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that the Physician Order for Life-Sustaining Treatment (POLST) form had appropriate Power of Attorney (POA) and/or concurring Physician signature for two of 24 sampled residents (R) (R#63 and R#66). Findings include: 1. A review of R#66's medical record revealed a POLST dated 12/7/2020 with a resident's representative signature and one physician's signature. The POLST was to allow a natural death for the resident. A review of the quarterly Minimum Data Set (MDS) dated [DATE] showed that the resident had a Brief Interview for Mental Status (BIMS) of 11, indicating the resident had moderately impaired cognition. During an interview on 8/26/21 at 10:37 a.m., R#66 stated that her POA makes financial decisions for her, but she was unsure if her POA has POA of her health treatment. During an interview on 8/26/21 at 12:48 p.m., the Business Office Manager (BOM) stated that the POA paperwork was usually done with the admission packet. The BOM stated that the POA or the resident signed the POLST. Once the POLST had been signed by the POA or resident (if capable), then the physician signed, and it went into the nurse's chart. The BOM stated that she was unaware of where the actual POA forms were. During an interview on 8/26/21 at 3:08 p.m., the Administrator stated that she did not have the POA form for R#66. 2. A review of R#63's medical record revealed a POLST dated 10/23/2020 for a Do Not Resuscitate (DNR) order with a signature by a resident's representative and only one physician's signature. The POLST form had a sticky note stating that there was no POA. Attempted to interview R#63 at 10:32 a.m., but the resident was confused. A review of the quarterly MDS dated [DATE] showed the resident had a BIMS of four, indicating the resident had a severely impaired cognition. During an interview on 8/26/21 at 3:08 p.m., the Administrator stated that R#63 did not have a POA. During interview on 8/27/21 at 1:46 p.m., the Administrator stated the nurses should know the code status of a resident before admission, and it should be on the POLST form. The Administrator acknowledged the lack of appropriate signatures on the POLST forms.