**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's choice of code status was documented accurately for 1 of 2 residents reviewed for advanced directives. (Resident 13) Finding includes: On [DATE] at 2:34 p.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to, dementia, acute respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body), and chronic kidney disease (condition where the kidneys are damaged and can't properly filter waste and fluid from the blood). An Out of Hospital Do Not Resuscitate declaration and order, a choice of treatment document, dated [DATE], was signed by the Resident's POA (power of attorney) and the resident's physician, the document indicated no CPR (cardiopulmonary resuscitation) to be performed. The CPR consent, dated [DATE], indicated to perform CPR while the resident was in the facility. The CPR consent was obtained by verbal phone consent of the Resident's POA and witnessed by two nurses on [DATE]. A review of the physician orders indicated the following: On [DATE] Code Status: Full Code (all possible life-saving measures taken in the event of a medical emergency, such as cardiac or respiratory arrest, including CPR). The order was discontinued on [DATE]. On [DATE]: Code Status: DNR (Do Not Resuscitate). The order was discontinued on [DATE]. On [DATE]: Code Status: DNR. The order was discontinued on [DATE]. On [DATE]: Code Status: DNR. A Social Service Comprehensive Note, dated [DATE], indicated the resident was a full code. A Social Service Comprehensive Note, dated [DATE], indicated the resident was a DNR. A Resident First Meeting Minutes Note, dated [DATE], indicated the Resident's code status remained a DNR. A Resident First Meeting Minutes Note, dated [DATE], indicated the Resident's code status remained a DNR. A Hospital History and Physical, dated [DATE], indicated the resident was a full code. No additional documentation was in the clinical record to reflect the change in advanced directive. During an interview with the DON (Director of Nursing) on [DATE] at 11:55 a.m., she indicated she was unsure why the advanced directive order was changed. The DON indicated there was no further documentation in the record that indicated a request from the POA to change the resident's advanced directive. On [DATE] at 11:45 a.m., the Administrator provided the facility's admission packet, dated [DATE]. The Administrator indicated this was the current admission packet used by the facility. The document indicated .Out of Hospital Do Not Resuscitate Declaration and Order .is used to state your wishes .The declaration may be canceled by you at any time by a signed and dated writing .or by communicated to health care providers at the scene the desire to cancel the order . On [DATE] at 1:08 p.m., the DON provided the Guidelines for DNR Order policy. The policy was dated, [DATE], the DON indicated this was a current policy used by the facility. The policy indicated, .2. A Do Not resuscitate Form shall be completed and signed .and placed in medical record .5. The interdisciplinary care planning team will review advance directives with the resident during quarterly Resident First Conference to determine if the resident wishes to make changes in such directives . 3.1-4(f)(5)

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 1 residents reviewed for Resident Assessment. (Resident 55) Findings includes: On 5/19/25 at 11:21 a.m., Resident 55's clinical record was reviewed. The diagnoses included, but were not limited to, lung cancer and lupus (disease when your body's immune system attacks your own organs and tissue). The progress notes, dated 4/18/25 at 3:01 p.m., indicated Resident 55 was discharged home with her husband. The discharge MDS assessment, dated 4/18/25, indicated Resident 55 was discharged to a short term general hospital. During an interview on 5/19/25 at 3:07 p.m., the Social Services Director (SSD) indicated Resident 55 was discharged home. During an interview on 5/20/25 at 10:52 a.m., the MDS nurse indicated Resident 55 was discharged home. The MDS was coded wrong. During an interview on 5/20/25 at 12:24 p.m., the MDS Consultant indicated they did not have a MDS coding policy. The facility followed the RAI (Resident Assessment Instrument) manual. 3.1-31(d)

5. On 6/19/23 at 10:37 a.m., Resident 41's clinical record was reviewed. The diagnoses included, but were not limited to, urinary tract infection, Parkinson's disease, and kidney failure. Resident 41's progress note dated, 3/16/23 at 1:35 p.m., indicated he was very agitated and was slurring his speech. He was transferred to the emergency room for evaluation and treatment. The Notice of Transfer or Discharge form, dated 3/16/23, lacked documentation of a written notification of the Notice of Transfer or Discharge form was given to Resident 41 and his resident representative. During and interview on 6/20/23 at 3:10 p.m., the Director of Nursing (DON) indicated the clinical record lacked the written notifications were given to the residents or the resident representatives. On 6/21/23 at 1:50 p.m., the Administrator provided the facility policy, Guidelines for Transfer and Discharge, dated 5/3/17 and indicated this was the policy currently being used by the facility. A review of the policy lacked information of Notice of Transfer or Discharge form being given to the resident and the resident representative. 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(A)(ii) 3. On 6/16/23 at 11:15 a.m., Resident 14's clinical record was reviewed. The diagnoses included, but were not limited to, pneumonia and Parkinson's disease. The resident was transferred to the hospital on 6/10/23. There was no documentation to indicate the resident and the resident's representative were notified of the transfer in writing. 4. On 6/16/23 at 11:35 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, urinary tract infection and pneumonia. The resident was transferred to the hospital on 5/23/23. There was no documentation to indicate the resident and the resident's representative were notified of the transfer in writing. Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was given to the resident and the resident representative for 5 of 5 residents reviewed for hospitalization. (Resident 4, Resident 48, Resident 14, Resident 25, Resident 41) Findings include: 1. On 6/19/23 at 11:42 a.m., Resident 4's clinical record was reviewed. The diagnosis included, but was not limited to, elevated white blood cell count. Resident 4's progress notes indicated the resident was sent to the hospital on 4/27/23. The Notice of Transfer or Discharge forms, dated 4/27/23, lacked documentation the resident and the resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the the Office of the State LTC (Long Term Care) Ombudsman, after the resident was sent out to the hospital. 2. On 6/19/23 at 11:17 a.m., Resident 48's clinical record was reviewed. The diagnoses included, but were not limited to, atrial fibrillation with RVR (rapid ventricular rate), pulmonary embolism (blood clot in the lung), and deep vein thrombosis and embolism (blood clot in the lower extremities). The resident's progress notes indicated he was sent to the hospital on 4/14/23. The Notice of Transfer or Discharge forms, dated 4/14/23, lacked documentation the resident and the resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the the Office of the State LTC (Long Term Care) Ombudsman, after the resident was sent out to the hospital.

5. On 6/19/23 at 10:37 a.m., Resident 41's clinical record was reviewed. The diagnoses included, but were not limited to urinary tract infection, Parkinson's disease, and kidney failure. Resident 41's progress note, dated 3/16/23 at 1:35 p.m., indicated he was very agitated and was slurring his speech. He was transferred to the emergency room for evaluation and treatment. The clinical record lacked documentation the facility's bed-hold policy was provided to the resident or the resident's representative. During and interview on 6/20/23 at 3:10 p.m., the Director of Nursing (DON) indicated the clinical record lacked the documentation the facility's bed-hold policy was provided to the resident or the resident's representative. On 6/21/23 at 1:50 p.m., the Administrator provided the facility policy, Guidelines for Transfer and Discharge, dated 5/3/17 and indicated this was the policy currently being used by the facility. A review of the policy indicated . c. In cases of emergency transfers, the notice of the bed-hold policy under the State plan and facility's bed-hold policy should be provided to the resident or resident's representative with 24 hours of the transfer . 3.1-12(a)(25) 3.1-12(a)(26) 3. On 6/16/23 at 11:15 a.m., Resident 14's clinical record was reviewed. The diagnoses included, but were not limited to, pneumonia and Parkinson's disease. The resident was transferred to the hospital on 6/10/23. There was no documentation to indicate the resident or the resident's representative were notified of information regarding the facility's bed-hold policy in writing. 4. On 6/16/23 at 11:35 a.m., Resident 25's clinical record was reviewed. The diagnoses included, but were not limited to, urinary tract infection and pneumonia. The resident was transferred to the hospital on 5/23/23. There was no documentation to indicate the resident or the resident's representative were notified of information regarding the facility's bed-hold policy in writing. Based on interview and record review, the facility failed to ensure the notification of the bed-hold policy required for residents who transferred to the hospital was provided in writing to the resident or the residents representative for 5 of 5 residents reviewed for hospitalization. (Resident 4, Resident 48, Resident 14, Resident 25, Resident 41). Findings include: 1. On 6/19/23 at 11:42 a.m., Resident 4's clinical record was reviewed. The diagnosis included, but was not limited to elevated white blood cell count. Resident 28's progress notes indicated the resident was sent to the hospital on 4/27/23. There was no documentation that a written notice that specified the facility's bed-hold policy was provided to the resident or the resident's representative. 2. On 6/19/23 at 11:17 a.m., Resident 48's clinical record was reviewed. The diagnoses included, but were not limited to, atrial fibrillation with RVR (rapid ventricular rate), pulmonary embolism (blood clot in the lung), and deep vein thrombosis and embolism (blood clot in the lower extremities). Resident 48's progress notes indicated the resident was sent to the hospital on 4/14/23. There was no documentation that a written notice that specified the facility's bed-hold policy was provided to the resident or the resident's representative.